<p> WEN OUNTY CHOOLS O C S Mark Cleveland Superintendent BOARD OF EDUCATION Phone (502) 484-3934 Fax (502) 484-9095 1600 Highway 22 East ~ Owenton, Kentucky 40359 ~ (502) 484-3934</p><p>INTEGRATED PEST MANAGEMENT IN SCHOOLS Pesticide Application Notification Request Form</p><p>Dear Parent/Guardian:</p><p>This Owen County School System has implemented an Integrated Pest Management (IPM) program in order to control pests in a way that minimizes economic, health, and environmental risks by implementing an inspection and monitoring program. The findings will then be evaluated to determine what action to take next, including the judicious use of the pesticides. If a pesticide application is determined to be needed, those individuals making the application would be required to be properly certified and licensed in keeping with applicable legal requirements for the IPM program. </p><p>Please complete and return this form if you want to be notified twenty-four (24) hours in advance of a planned pesticide application. Certain pesticide applications, such as the application of paste or gel bait insecticides, do not require notification of planned application. In the case of an emergency pesticide application, you will be notified as soon as possible after the application with an explanation as to why the application was made. This information is available to all parents and employees requesting it.</p><p>For questions regarding the Integrated Pest Management program, contact Dan Logan, Maintenance Supervisor for Owen County Schools at 502-484-4005.</p><p>_____Yes, I do want to be notified 24 hours in advance of a planned pesticide application or as soon as possible after an emergency application.</p><p>______Name of Student (Please Print) School</p><p>______Name of Individual to be Notified (Please Print) Telephone Number</p><p>______Signature Date</p><p>Equal Opportunity Employer M/F/D WEN OUNTY CHOOLS O C S Mark Cleveland Superintendent BOARD OF EDUCATION Phone (502) 484-3934 Fax (502) 484-9095 1600 Highway 22 East ~ Owenton, Kentucky 40359 ~ (502) 484-3934</p><p>ADVANCE NOTIFICATION FORM</p><p>Date______</p><p>Dear Parent/Guardian:</p><p>This information is being sent to you based on your request to receive advance notification of scheduled pesticide applications. This advance notification does not apply to paste or gel bait insecticides or to sanitizers, disinfectants, and the like.</p><p>Scheduled date and time of pesticide application: ______</p><p>Location of pesticide application: ______</p><p>Pest(s) targeted: ______</p><p>Pesticide(s) applied (Brand Name)</p><p>______</p><p>Active ingredients of pesticide(s) applied: ______</p><p>Method of application: ______</p><p>______</p><p>Questions regarding the health effects of the pesticides to be used should be referred to your health care provider.</p><p>Labels and Material Safety Data Sheets (MSDS) are on file with the Integrated Pest Management (IPM) Coordinator. For service or applications questions or for copies of the labels or MSDS’s, please contact the IPM Coordinator, Keith Bolen, at 502-484-3934.</p><p>Equal Opportunity Employer M/F/D WEN OUNTY CHOOLS O C S Mark Cleveland Superintendent BOARD OF EDUCATION Phone (502) 484-3934 Fax (502) 484-9095 1600 Highway 22 East ~ Owenton, Kentucky 40359 ~ (502) 484-3934 EMERGENCY PESTICIDE APPLICATION NOTIFICATION FORM</p><p>Date______</p><p>Dear Parent/Guardian:</p><p>This information is being sent to you based on your request to receive advance notification of scheduled pesticide applications. This advance notification does not apply to paste or gel bait insecticides or to sanitizers, disinfectants, and the like. The following information applies to an emergency application of pesticides.</p><p>Scheduled date and time of pesticide application: ______</p><p>Location of pesticide application: ______</p><p>Pest(s) targeted: ______</p><p>Pesticide(s) applied (Brand Name)</p><p>______</p><p>Active ingredients of pesticide(s) applied: ______</p><p>Method of application: ______</p><p>Reason for emergency application of pesticides: ______</p><p>Questions regarding the health effects of the pesticides to be used should be referred to your health care provider.</p><p>Labels and Material Safety Data Sheets (MSDS) are on file with the Integrated Pest Management (IPM) Coordinator. For service or applications questions or for copies of the labels or MSDS’s, please contact the IPM Coordinator, Dan Logan, at 502-484-4005.</p><p>Equal Opportunity Employer M/F/D</p>