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Request for Continuing Certification Hour (CCH)
Approval Worksheet Submission Form (pdf format)





Instructions for Completing the CCH Approval Worksheet


  1. a) Enter the title of your program as it will be advertised to the public.

    b) List site location - street address, city, state, zip code.

    c) Include definitions of any acronyms used in your presentation descriptions.

  2. All programs approved for CCHs must be open to the public. These programs, including the program sponsor contact's name and phone number will be posted to the Office of Indiana State Chemist (OISC) website when approved.

  3. Enter the dates for the conference/program. Enter the link to your on-line registration form to this program if available.

  4. a) Use additional worksheets, as needed, for multiple days.  If submitting additional worksheets via e-mail, please indicate how many pages you will be sending.

    b) Do not list on this worksheet any presentations that you believe do not have any pesticide or fertilizer applicator/technician competency content in them.  Subject matter and content must include, but may not be limited to, at least one (1) of the following:

    PESTICIDES:

    1. Pest identification
    2. Pest biology
    3. Pesticide chemistry
    4. Pesticide equipment calibration and maintenance
    5. Pesticide use
    6. Pest management by cultural, mechanical or other non-pesticide means, including, but not limited to the following:
      1. Sanitation;
      2. Exclusion;
      3. Fertilization;
      4. Irrigation;
      5. Soil compaction; and
      6. Pest monitoring
    7. Pesticide label interpretation
    8. Pesticide label safety measures
    9. Public and customer safety
    10. Consumer and customer complaints
    11. Applicator safety
    12. Environmental safety
    13. Associated state and federal laws or regulations affecting pesticides or pesticide users

    FERTILIZERS:

    1. Fertilizer material storage
    2. Fertilizer material chemistry
    3. Fertilizer material equipment calibration and maintenance
    4. Fertilizer material use
    5. Fertilizer material transportation
    6. Fertilizer material application development and implementation
    7. Spill response procedures
    8. Public and customer safety
    9. Public and customer concerns
    10. Applicator safety
    11. Environmental safety
    12. Environmental issues
    13. Employee training
    14. Associated state and federal laws or regulations affecting fertilizer applicators

    c) Subject matter and content may not include any of the following:

    1. Product or service sales or promotions
    2. Employee hiring or retention
    3. General business practices

    d) List for each presentation all of the categories for whicih you feel the presentation material is appropriate. The categories you list should be based on specific presentation content and your anticipated target audience. The category descriptions are as follows:

    • 1 - Agricultural Pest Management
    • 2 - Forest Pest Management
    • 3a - Ornamental Pest Management
    • 3b - Turf Management
    • 4 - Seed Treatment
    • 5 - Aquatic Pest Management
    • 6 - Industrial Weed Management
    • 7a - Industrial, Institutional, Structural & Health-Related Pest Management
    • 7b - Termite Control
    • 7d - Fumigation
    • 8 - Mosquito Management (Community-Wide)
    • 11 - Aerial Application
    • 12 - Wood Destroying Pest Inspection
    • 14 - Agricultural Fertilizer Application

  5. a) Completed CCH approval worksheet requests must be submitted to OISC at least three (3) weeks in advance of the program date. If you suspect that there may be a problem with timely submission of the request, contact Leo Reed at (765) 494-1588 for guidance.

    b) Completed worksheets may be mailed, faxed or e-mailed to:

    Cassie Davis
    Office of Indiana State Chemist
    175 S. University Street
    West Lafayette, IN 47907-2063
    Telephone: 765-494-9563
    Fax: 765-494-4331
    E-mail: davi1090@purdue.edu

    c) CCHs will be awarded as whole numbers for each applicable category on a per-day basis. One (1) CCH will be awarded for one (1) hour of appropriate presentation time. Questions or discrepancies about the number of CCHs awarded should be directed immediately upon your notification of approval/denial from OISC. Inquiries should be directed to Leo Reed at (765) 494-1588 or by e-mail: reedla@purdue.edu



View the CCH Worksheet  (pdf, 262kb)

Please note: This worksheet is in pdf format. Visit the Adobe website to download the most current version of their free Adobe Reader.