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pdfOMB Control #: 2070-0200
Expiration Date: MM/DD/YYYY
School IPM Great Start Award
The U.S. Environmental Protection Agency’s (EPA) School Integrated Pest Management (IPM)
Great Start Award is presented to school districts that have made a commitment to implement an
effective Integrated Pest Management program and that have taken the first steps towards
implementing IPM. The Great Start Award is one of five levels of IPM awards, which the EPA
presents to school districts or individuals. To find out which level of recognition is the best fit for
your district, visit [insert website].
Recipients of the School IPM Great Start Award will receive:
•
•
•
•
A “Great Start in School IPM” certificate signed by an EPA official;
Recognition on EPA’s web site – [insert web site];
Access to topical webinars, trainings, events and recognition and mentoring
opportunities;
Regular e-mail updates aimed at advancing your school IPM program.
Eligibility
For a school district to receive the Great Start Award, the district must:
• Comply with all state laws;
• Only allow pesticides to be applied by a certified pesticide applicator;
• Have a designated IPM Coordinator that is receiving regular IPM training;
• Have a written IPM Policy;
• Complete a self-assessment using an IPM checklist which addresses the pest-conducive
conditions and pest problems present in the district.
How to Apply
Interested candidates should complete the attached application and submit the application by email, U.S. Mail, facsimile or special delivery services (Federal Express, United Parcel Services,
etc.).
E-mail:
ATTN: [insert email]
Facsimile:
ATTN: [insert facsimile]
U.S. Mail (or Special Delivery):
ATTN: [inset mailing address]
Paperwork Reduction Action Notice: The public reporting and record keeping burden for this collection is estimated to average about 4 hours per response,
including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the
Form #: 9600-009
OMB Control #: 2070-0200
Expiration Date: MM/DD/YYYY
collection of information. This is a voluntary collection. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of
information unless it displays a valid OMB Control Number. The OMB Control Number of this collection is 2070-0200. Send comments regarding this burden
estimate or any other aspect of this collection of information, including suggestions for reducing the burden, to Director, Collection Strategies Division (Mail Code
2822T), U.S. Environmental Protection Agency, Washington, DC 20460. Include the OMS control number in any correspondence, but do not submit the form or
report to this address. The form should be submitted in accordance with the instructions for the form.
The application is a fill-in form, which will allow you to save what you have filled in on your
computer and submit it electronically via e-mail.
Applications for the Great Start Award are accepted year-round on a non-competitive basis. For
specific questions, contact the School IPM Awards Coordinator at [insert contact information].
Form #: 9600-009
OMB Control #: 2070-0200
Expiration Date: MM/DD/YYYY
Guidance for Completing the Great Start Application
Clarification of the terms used in the attached application, guidance about how to get started with
IPM in your school district, and an IPM self-assessment checklist can be found at [insert
website].
School System/District Information
Please provide all of the information requested in the table below. Note: If the contact person for this
application is not in school during the summer break, please provide additional contact information
(e.g., cell phone, alternate contacts) to allow EPA to contact you if necessary about your application.
The application is a fill-in form, which will allow you to type your answers directly into the
form, save what you have filled in on your computer, and submit it electronically via e-mail.
IPM Coordinator Contact Information
School System/District Name:
Name of IPM Coordinator
Title
Department
Address
City, State, Zip Code
Telephone
Fax Number
E-mail Address
School System/District Profile
Total Number of Students
Total Number of Staff
Total Number of Facilities in Your
System/District (e.g., 45 schools, 5
educational support buildings)
Age Range of All System/District Facilities
(e.g., 5-90 years old)
Total Square Footage (ft2) of All
System/District Facilities (e.g., 1.5 million
ft2)
Total School District Budget
Number of School Facilities in Your
School System/District Participating in the
School IPM Program
Form #: 9600-009
OMB Control #: 2070-0200
Expiration Date: MM/DD/YYYY
School System/District Information Statement of Compliance
with State Law
I certify that
School District is in compliance with the laws of the State of
, including the laws that pertain to pest management and pesticide application.
Signature
Print Name
Date
Your District’s Integrated Pest Management Program
Coordinator: Who is your district’s Integrated Pest Management Coordinator? When did this
person become the IPM coordinator? What is the role the IPM coordinator in managing pests and
pest-conducive conditions in your district?
Education: Does your district’s IPM Coordinator receive at least eight (8) hours of training per
year in Integrated Pest Management techniques? How or where does the coordinator receive this
training?
Form #: 9600-009
OMB Control #: 2070-0200
Expiration Date: MM/DD/YYYY
Policy: Does your district have a written IPM Policy? A sample IPM Policy can be found at
[insert link]. Please attach a copy of the written IPM policy to this application.
Self-Assessment: Have you completed a self-assessment using an IPM checklist for some or all
of the facilities in your district? An example of a self-assessment checklist can be found at [insert
link]. For what portion of the facilities in your district has an IPM self-assessment been
completed? Your application will be evaluated on whether you have completed a self-assessment
for at least some of the schools in your district, not on the findings of the self-assessment. Please
attach a copy of the completed checklist/s to this application.
Certified Applicator: Are all pesticide applications in your district performed by a certified
applicator? Please attach proof of certification to this application.
Narrative: Please use the space below to detail any aspects of your district’s Integrated Pest
Management program which you have not mentioned anywhere else in this application.
4
OMB Control #: 2070-0200
Expiration Date: MM/DD/YYYY
School IPM Leadership Award
The U.S. Environmental Protection Agency’s (EPA) School Integrated Pest Management
(IPM) Leadership Award is presented to schools and/or school districts who make a seniorlevel commitment to establish and maintain sustainable IPM programs. The Leadership
Award is one of five levels of IPM awards, which the EPA presents to school districts or
individuals. To find out which level of recognition is the best fit for your district, visit [insert
website].
Recipients of the School IPM Leadership Award will receive:
•
•
•
•
A “Leadership in School IPM” certificate signed by an EPA official;
Recognition on EPA’s Web site – [insert website];
Access to topical web conference calls, training, events, and recognitionand
mentoring opportunities; and
Regular e-mail updates aimed at advancing your school IPM program.
Eligibility
For a school district to receive the National Leadership Award, the district must:
• Meet all requirements of the Great Start Award, including compliance with all
relevant state laws;
• Form an Environmental Health/IPM Committee;
• Provide IPM education for Custodial, Maintenance, Groundskeeper, Kitchen, and
Health staff members;
• Have a written IPM Plan in place;
• Conduct monthly inspections including insect and rodent monitoring stations;
• Provide pesticide use records and monitoring records;
• Store pesticides properly and notify the public when they are used;
• Maintain trash areas and keep dumpsters at least 50 feet from any school facility;
• Use door sweeps;
• Manage vegetation near buildings.
How to Apply
Interested candidates should complete the School IPM National Leadership Award application
and submit by e-mail, U.S. Mail, facsimile or special delivery services (Federal Express, United
Parcel Services, etc.). Applications for the Leadership Award are accepted year-round on a noncompetitive basis. For specific questions, contact [insert contact information].
Paperwork Reduction Action Notice: The public reporting and record keeping burden for this collection is estimated to average about 38 hours per response,
including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the
collection of information. This is a voluntary collection. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of
information unless it displays a valid OMB Control Number. The OMB Control Number of this collection is 2070-0200. Send comments regarding this
burden estimate or any other aspect of this collection of information, including suggestions for reducing the burden, to Director, Collection Strategies
Division (Mail Code 2822T), U.S. Environmental Protection Agency, Washington, DC 20460. Include the OMS control number in any correspondence, but
do not submit the form or report to this address. The form should be submitted in accordance with the instructions for the form.
1
OMB Control #: 2070-0200
Expiration Date: MM/DD/YYYY
The application is a fill-in form, which will allow you to save what you have filled in on
your computer and submit it electronically via e-mail.
All applications may be submitted by e-mail, facsimile, U.S. Mail, or special delivery 2 services
(Federal Express, United Parcel Services, etc.).
E-mail:
ATTN: [insert email]
2
OMB Control #: 2070-0200
Expiration Date: MM/DD/YYYY
Facsimile:
ATTN: [insert facsimile]
U.S. Mail (or Special Delivery):
ATTN: [inset mailing address]
Guidance for Completing the Leadership Application
Clarification of the terms used in the attached application can be found at [insert website].
School or School System/District Information
Please provide all of the information requested in the table below. Note: If the contact person
for this application is not in school during the summer break, please provide additional
contact information (e.g., cell phone, alternate contacts) to allow EPA to contact you about
your application, if necessary.
The application is a fill-in form, which will allow you to type your answers directly into the
form, save what you have filled in on your computer, and submit it electronically via e-mail.
IPM Coordinator Contact Information
School System/District Name
Name(s) of IPM Coordinator
and IPM Team Members (if
necessary, please include
an additional sheet listing all
IPM Team members)
Title
Department
Address
City, State, Zip Code
Telephone
Fax Number
E-mail Address
School System/District Profile
Total Number of Students
Total Number of Staff
Total Number of Facilities in
Your System/District (e.g., 45
schools, 5 educational
support buildings)
Age Range of All
System/District Facilities
(e.g., 5-90 years old)
Total Square Footage (ft2) of
All System/District Facilities
(e.g., 1.5 million ft2)
Total School District Budget
3
OMB Control #: 2070-0200
Expiration Date: MM/DD/YYYY
Number of School Facilities in
Your School System/District
Participating in the School
IPM Program
Please review the statements in each section and check all boxes that apply to your school or
school district IPM program.
School System/District Information Statement of
Compliance with State Law
I certify that
State of
application.
Signature
School District is in compliance with the laws of the
, including the laws that pertain to pest management and pesticide
Print Name
Date
Your District’s Integrated Pest Management Program
Great Start Award: Has your district previously received the Great Start Award? If so,
please state when your district received the award. If not, please briefly explain how your
district meets the requirements of the Great Start award (information on the Great Start award
can be found on the same website as the information for the Leadership award: [insert
website]).
4
OMB Control #: 2070-0200
Expiration Date: MM/DD/YYYY
Environmental Health/IPM Committee: Please describe the structure, membership,
responsibilities, and activities of your school district’s Environmental Health/IPM
Committee.
5
OMB Control #: 2070-0200
Expiration Date: MM/DD/YYYY
Staff Education: Please discuss the IPM education your district provides for Custodial,
Maintenance, Groundskeeper, Kitchen, and Health staff members. Make sure to note the
frequency, duration, and structure of this education. If you have any documents used in this
process, please attach them to this application.
6
OMB Control #: 2070-0200
Expiration Date: MM/DD/YYYY
IPM Plan: Does your district have a written IPM Policy? A sample IPM Plan can be found at
[insert link]. Please attach a copy of your school district’s IPM Plan to this application.
Inspections: Does your district conduct monthly inspections including the use of insect and
rodent monitoring stations? Please explain your district’s process for carrying out these
inspections. If you have any documents relevant for this item, such as a sample
inspection form, please attach them to this application.
7
OMB Control #: 2070-0200
Expiration Date: MM/DD/YYYY
Pesticide Use and Monitoring Records: Does your district keep records of pesticide use
and of the results of its monthly inspections? Please describe your district’s process for
keeping these records and, if your district does so, reviewing and taking action based on the
records. Please attach a copy of a pesticide use record used by your district to this
application (can be a sample form or an actually used form).
8
OMB Control #: 2070-0200
Expiration Date: MM/DD/YYYY
Pesticide Notification and Storage: Does your district follow the recommended procedures
for pesticide use notification and pesticide storage? Please describe how your district notifies
the public of pesticide use and how pesticides are stored in your district. If you have any
supporting documentation, such as a sample notification letter or posting, or photos of
your pesticide storage area, please attach it to this application.
9
OMB Control #: 2070-0200
Expiration Date: MM/DD/YYYY
Trash Areas and Dumpsters: Does your district meet the requirements for proper
maintenance, sanitation, and placement of trash areas and dumpsters? If you would like to
provide photos of trash areas and dumpsters in your district, please attach them to this
application.
Door Sweeps: Has your district installed door sweeps on exterior doors and are the door
sweeps of proper quality? Please mention, if available, the brand of the door sweeps your
district uses.
Vegetation near Buildings: What is your district’s policy regarding vegetation near
buildings? Does your district meet the given requirements for visibility between structures
and vegetation?
10
OMB Control #: 2070-0200
Expiration Date: MM/DD/YYYY
Narrative: Please use the space below to detail any aspects of your district’s Integrated Pest
Management program which you have not mentioned anywhere else in this application.
11
OMB Control #: 2070-0200
Expiration Date: MM/DD/YYYY
School IPM Excellence Award
The U.S. Environmental Protection Agency’s (EPA) School Integrated Pest Management
(IPM) Excellence Award is presented to school districts that have implemented
exemplary IPM programs The Excellence Award is one of five levels of IPM awards,
which the EPA presents to school districts or individuals. To find out which level of
recognition is the best fit for your district, visit [insert website].
Recipients of the School IPM Excellence Award will receive:
•
•
•
•
An “Excellence in School IPM” certificate signed by an EPA official;
Recognition on EPA’s Web site – [insert website];
Access to topical web conference calls, training, events, and recognition and
mentoring opportunities; and
Regular e-mail updates aimed at advancing your school IPM program.
Eligibility
For a school district to receive the Excellence Award, the district must:
• Meet all of the requirements of the Leadership Award, including compliance with
all relevant state laws;
• Prove that the Environmental Health Committee, Pest Management Professional &
school administration follow the IPM Plan proactively;
• Update the IPM plan annually;
• Provide IPM education and award certificates to all staff including teachers and
coaches;
• Conduct full quarterly inspections;
• Keep detailed maintenance and pest complaint records;
• Follow guidelines for pesticide selection and application;
• Exercise proper sanitation including: proper food storage, clean and sanitary;
kitchens and clutter-free classrooms and buildings;
• Keep structures free of gaps, holes and other pest entry points;
• Maintain the cleanliness of building exteriors.
Paperwork Reduction Action Notice: The public reporting and record keeping burden for this collection is estimated to average
about 22 hours per response, including the time for reviewing instructions, searching existing data sources, gathering and
maintaining the data needed, and completing and reviewing the collection of information. This is a voluntary collection. An
agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a
valid OMB Control Number. The OMB Control Number of this collection is 2070-0200. Send comments regarding this
burden estimate or any other aspect of this collection of information, including suggestions for reducing the burden, to
Director, Collection Strategies Division (Mail Code 2822T), U.S. Environmental Protection Agency, Washington, DC
20460. Include the OMS control number in any correspondence, but do not submit the form or report to this address. The
form should be submitted in accordance with the instructions for the form.
1
OMB Control #: 2070-0200
Expiration Date: MM/DD/YYYY
Instructions
Interested candidates should complete the attached application and submit the application
by e-mail, U.S. Mail, facsimile or special delivery services (Federal Express, United Parcel
Services, etc.).
E-mail:
ATTN: [insert email]
Facsimile:
ATTN: [insert facsimile]
U.S. Mail (or Special Delivery):
ATTN: [inset mailing address]
2
OMB Control #: 2070-0200
Expiration Date: MM/DD/YYYY
The application is a fill-in form, which will allow you to save what you have filled in
on your computer and submit it electronically via e-mail.
Applications for the Excellence Award are should be submitted by November 1st.
Awardees will be selected by the following January. For specific questions, contact the
School IPM Awards Coordinator at [insert contact information].
Guidance for Completing the Excellence Application
Clarification of the terms used in the attached application can be found at [insert website].
School System/District Information
Please provide all of the information requested in the table below. Note: If the contact person
for this application is not in school during the summer break, please provide additional contact
information (e.g., cell phone, alternate contacts) to allow EPA to contact you if necessary
about your application.
The application is a fill-in form, which will allow you to type your answers directly into
the form, save what you have filled in on your computer, and submit it electronically via
e-mail.
IPM Coordinator Contact Information
School System/District Name:
Name of IPM Coordinator
Title
Department
Address
City, State, Zip Code
Telephone
Fax Number
E-mail Address
School System/District Profile
Total Number of Students
Total Number of Staff
Total Number of Facilities in Your
System/District (e.g., 45 schools, 5
educational support buildings)
Age Range of All System/District Facilities
(e.g., 5-90 years old)
Total Square Footage (ft2) of All
System/District Facilities (e.g., 1.5 million
ft2)
Total School District Budget
Number of School Facilities in Your
School System/District Participating in the
School IPM Program
3
OMB Control #: 2070-0200
Expiration Date: MM/DD/YYYY
School System/District Information Statement of
Compliance with State Law
I certify that
State of
application.
Signature
School District is in compliance with the laws of the
, including the laws that pertain to pest management and pesticide
Print Name
Date
Your District’s Integrated Pest Management Program
IPM STAR: If your school district currently has certification through the IPM STAR
program, it is eligible to receive the Excellence Award automatically. If your district is
IPM STAR-certified, please attach documentation that confirms this certification to
this application.
Leadership Award: Has your school district previously received the Leadership Award? If
so, please state when your district received this award. If not, please affirm that your
district meets the criteria to receive the Leadership Award. The requirements of the
Leadership Award are available at this website: [insert website]. The IPM Plan is an
especially important component of the Leadership Award criteria and is also necessary to
meet the criteria of the Excellence Award. Please attach your district’s written IPM
Plan to this application.
4
OMB Control #: 2070-0200
Expiration Date: MM/DD/YYYY
Coordination of IPM Plan, Committee, Administration, and Pest Management
Professional: To qualify for the Excellence Award, a district must not only have an IPM
Plan and Environmental Health/IPM Committee but also demonstrate that the Plan is being
implemented and that the Committee is involved with the decisions of the district’s
administration and pest management professionals. Please describe how your district’s pest
management professional works with your district’s IPM Plan and how the Environmental
Health/IPM Committee interacts with district administration and pest management
professionals.
5
OMB Control #: 2070-0200
Expiration Date: MM/DD/YYYY
IPM Plan Updates: To be successful, an IPM Plan must be adaptive to changing
conditions and needs. The IPM Plan must be updated annually to meet the criteria of the
Excellence Award; please describe the process by which your district updates its IPM Plan.
Who is responsible for updating the plan? What factors are considered?
6
OMB Control #: 2070-0200
Expiration Date: MM/DD/YYYY
Staff Education: The Excellence Award requires that all staff, including teachers, coaches,
and administrative staff, receive IPM education and certificates (see application guide for
specific requirements). Please describe the education your district provides to staff. If you
have documents used for IPM education, such as lesson plans or training modules,
please attach it to this application.
7
OMB Control #: 2070-0200
Expiration Date: MM/DD/YYYY
Full Quarterly Inspections: In addition to the monthly monitoring inspections required at
the Leadership Award level, the Excellence Award requires that your district conduct full
inspections on a quarterly basis. These full inspections should be conducted by the IPM
Coordinator and at least one other member of the Committee, accompanied by the district’s
pest management professional if the district contracts services from a pest management
professional. Please describe the process used in these inspections. If you have any
documents used for these inspections, please attach them to this application.
8
OMB Control #: 2070-0200
Expiration Date: MM/DD/YYYY
Pest Sighting and Maintenance Records: Please describe how your school monitors and
records pest sightings and pest-related maintenance issues. Please attach the forms used
for pest sightings and maintenance requests to this application.
9
OMB Control #: 2070-0200
Expiration Date: MM/DD/YYYY
Pesticide Selection and Application: Please describe your district’s process for
determining when and how to use pesticides, which pesticides your district uses, and how
frequently your district uses those pesticides. This includes any pesticides used by outside
contractors. If you have a document explaining your district’s pesticide selection and
application protocol, please attach it to this application.
10
OMB Control #: 2070-0200
Expiration Date: MM/DD/YYYY
Food Storage, Kitchen Sanitation, and Interior Clutter: How does your district control
food storage, sanitation, and clutter so as to minimize pest-conducive conditions inside
school buildings? It is advised that you submit a filled-in checklist (of the same type
used in the Great Start Award application) to verify your district’s control of these
factors. In addition, please attach to this application any other documents that might
be helpful in establishing your district’s sanitation policies and conditions.
11
OMB Control #: 2070-0200
Expiration Date: MM/DD/YYYY
Entry Points: Please verify that your district’s structures are free of gaps, holes, and other
entry points for pests. These are primarily on the exterior of buildings, although interior
gaps should be addressed as well. Please explain the process by which your district
monitors for entry points and addresses them when they are identified. It is recommended
that you submit a filled-in checklist (as in the previous requirement) to verify your
district’s control of structural entry points.
12
OMB Control #: 2070-0200
Expiration Date: MM/DD/YYYY
Exterior Clutter and Harborage: Please verify that your district controls clutter and
harborage on school grounds. Explain how your district monitors for clutter and harborage
and how it addresses it when it is identified. Again, it is recommended that you submit a
filled-in checklist to support your application.
13
OMB Control #: 2070-0200
Expiration Date: MM/DD/YYYY
Narrative: Please use the space below to detail any aspects of your district’s Integrated
Pest Management program which you have not mentioned anywhere else in this
application.
14
OMB Control #: 2070-0200
Expiration Date: MM/DD/YYYY
School IPM Sustained Excellence Award
The U.S. Environmental Protection Agency’s (EPA) School Integrated Pest Management
(IPM) Sustained Excellence Award is presented to school districts that have been given
the Excellence Award in the past and that have demonstrated the continued success and
sustainability of their IPM programs. The Sustained Excellence Award is one of five
levels of IPM awards, which the EPA presents to school districts or individuals. To find
out which level of recognition is the best fit for your district, visit [insert website].
Recipients of the School IPM Sustained Excellence Award will receive:
•
•
•
•
A “Sustained Excellence in School IPM” certificate signed by an EPA official;
Recognition on EPA’s web site – [insert web site];
Access to topical webinars, trainings, events and recognition andmentoring
opportunities;
Regular e-mail updates aimed at advancing your school IPM program.
Eligibility
For a school district to receive the Sustained Excellence Award, the district must:
• Have received the Excellence Award at least two years prior to applying for the
Sustained Excellence award;
• Presently meet all requirements for receiving the Excellence award;
• Provide documentation of its method for making its IPM program sustainable;
• Provide documentation of the results its IPM program has achieved;
• Demonstrate how it has communicated about its IPM program both internallyand
externally.
How to Apply
Interested candidates should complete the attached application and submit the application by
e-mail, U.S. Mail, facsimile or special delivery services (Federal Express, United Parcel
Services, etc.).
E-mail:
ATTN: [insert email]
Facsimile:
ATTN: [insert facsimile]
U.S. Mail (or Special Delivery):
ATTN: [inset mailing address]
Paperwork Reduction Action Notice: The public reporting and record keeping burden for this collection is estimated to average
about 31 hours per response, including the time for reviewing instructions, searching existing data sources, gathering and
maintaining the data needed, and completing and reviewing the collection of information. This is a voluntary collection. An
agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a
valid OMB Control Number. The OMB Control Number of this collection is 2070-0200. Send comments regarding this
burden estimate or any other aspect of this collection of information, including suggestions for reducing the burden, to
Director, Collection Strategies Division (Mail Code 2822T), U.S. Environmental Protection Agency, Washington, DC
20460. Include the OMS control number in any correspondence, but do not submit the form or report to this address. The
form should be submitted in accordance with the instructions for the form.
1
OMB Control #: 2070-0200
Expiration Date: MM/DD/YYYY
The application is a fill-in form, which will allow you to save what you have filled in on
your computer and submit it electronically via e-mail.
Applications for the Sustained Excellence Award for a given year should be submitted by
November 1st. Awardees will be selected by the following January. For specific questions,
contact the School IPM Awards Coordinator at [insert contact information].
2
OMB Control #: 2070-0200
Expiration Date: MM/DD/YYYY
Guidance for Completing the Sustained Excellence Application
Clarification of the terms used in the attached application, guidance about how to get
started with IPM in your school district, and an IPM self-assessment checklist can be
found at [insert website].
School or School System/District Information
Please provide all of the information requested in the table below. Note: If the contact person
for this application is not in school during the summer break, please provide additional
contact information (e.g., cell phone, alternate contacts) to allow EPA to contact you if
necessary about your application.
The application is a fill-in form, which will allow you to type your answers
directly into the form, save what you have filled in on your computer, and
submit it electronically via e-mail.
IPM Coordinator Contact Information
School System/District Name:
Name of IPM Coordinator
Title
Department
Address
City, State, Zip Code
Telephone
Fax Number
E-mail Address
School System/District Profile
Total Number of Students
Total Number of Staff
Total Number of Facilities in Your
System/District (e.g., 45 schools, 5
educational support buildings)
Age Range of All System/District Facilities
(e.g., 5-90 years old)
Total Square Footage (ft2) of All
System/District Facilities (e.g., 1.5 million
ft2)
Total School District Budget
Number of School Facilities in Your
School System/District Participating in the
School IPM Program
3
OMB Control #: 2070-0200
Expiration Date: MM/DD/YYYY
Statement of Compliance with State Law
I certify that
School District is in compliance with the laws of the
State of
, including the laws that pertain to pest management and
pesticide application.
Signature
Print Name
Date
Your District’s Integrated Pest Management Program
Previous Excellence Award: When did your school district receive the Excellence
Award?
4
OMB Control #: 2070-0200
Expiration Date: MM/DD/YYYY
IPM STAR: If your school district currently has certification through the IPM STAR
program, it automatically meets the criteria of the Excellence Award (it still must
demonstrate that it meets the additional criteria required by the Sustained Excellence
Award, though). If your district is IPM STAR-certified, please attach documentation
that confirms this certification to this application.
Leadership Award: Please affirm that your district meets the criteria to receive the
Leadership Award. The requirements of the Leadership Award are available at this
website: [insert website]. The IPM Plan is an especially important component of the
Leadership Award criteria and is also necessary to meet the criteria of the Excellence
Award. Please attach your district’s written IPM Plan to this application.
5
OMB Control #: 2070-0200
Expiration Date: MM/DD/YYYY
Coordination of IPM Plan, Committee, Administration, and Pest Management
Professional: To qualify for the Sustained Excellence Award, a district must not only
have an IPM Plan and Environmental Health/IPM Committee but also demonstrate that
the Plan is being implemented and that the Committee is involved with the decisions of
the district’s administration and pest management professionals. Please describe how
your district’s pest management professional works with your district’s IPM Plan and
how the Environmental Health/IPM Committee interacts with district administration and
pest management professionals.
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IPM Plan Updates: To be successful, an IPM Plan must be adaptive to changing
conditions and needs. The IPM Plan must be updated annually to meet the criteria of the
Sustained Excellence Award; please describe the process by which your district updates
its IPM Plan. Who is responsible for updating the plan? What factors are considered?
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Staff Education: The Sustained Excellence Award requires that all staff, including
teachers, coaches, and administrative staff, receive IPM education and certificates (see
application guide for specific requirements). Please describe the education your district
provides to staff. If you have documents used for IPM education, such as lesson plans
or training modules, please attach it to this application.
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Full Quarterly Inspections: In addition to the monthly monitoring inspections required
at the Leadership Award level, the Sustained Excellence Award requires that your district
conduct full inspections on a quarterly basis. These full inspections should be conducted
by the IPM Coordinator and at least one other member of the Committee, accompanied
by the district’s pest management professional if the district contracts services from a
pest management professional. Please describe the process used in these inspections. If
you have any documents used for these inspections, please attach them to this
application.
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Pest Sighting and Maintenance Records: Please describe how your school monitors
and records pest sightings and pest-related maintenance issues. Please attach the forms
used for pest sightings and maintenance requests to this application.
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OMB Control #: 2070-0200
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Pesticide Selection and Application: Please describe your district’s process for
determining when and how to use pesticides, which pesticides your district uses, and how
frequently your district uses those pesticides. This includes any pesticides used by outside
contractors. If you have a document explaining your district’s pesticide selection and
application protocol, please attach it to this application.
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OMB Control #: 2070-0200
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Food Storage, Kitchen Sanitation, and Interior Clutter: How does your district control
food storage, sanitation, and clutter so as to minimize pest-conducive conditions inside
school buildings? It is advised that you submit a filled-in checklist (of the same type
used in the Great Start Award application) to verify your district’s control of these
factors. In addition, please attach to this application any other documents that
might be helpful in establishing your district’s sanitation policies and conditions.
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Entry Points: Please verify that your district’s structures are free of gaps, holes, and other
entry points for pests. These are primarily on the exterior of buildings, although interior
gaps should be addressed as well. Please explain the process by which your district
monitors for entry points and addresses them when they are identified. It is
recommended that you submit a filled-in checklist (as in the previous requirement)
to verify your district’s control of structural entry points.
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Exterior Clutter and Harborage: Please verify that your district controls clutter and
harborage on school grounds. Explain how your district monitors for clutter and
harborage and how it addresses it when it is identified. Again, it is recommended that
you submit a filled-in checklist to support your application.
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Program Sustainability: Please describe your school district’s strategy and efforts to
make its School IPM program sustainable. If you have a written sustainability plan,
please attach it to this application.
Questions to consider:
• Since winning the Excellence Award, what steps have you taken to put in place
policies or procedures that ensure your IPM plan will be sustained on a long-term
basis?
• How has the role of your IPM Coordinator/IPM Team changed over time? How
have you ensured the continued buy-in from team members, decision-makers,
staff, and the community over the years? How do you keep staff and others up-todate on your program and changes in policies or procedures related to IPM?
• What steps have you taken to ensure that your IPM program maintains top-level
administrative support? For example, how do you engage new system
administrators about IPM issues and your IPM program? How have you used
administrators as advocates for your IPM program?
• What obstacles have you encountered in advancing and sustaining your IPM
program? What steps have you taken to address these obstacles? How has
receiving a National Excellence Award helped you to advance your programand
address challenges?
• How do you maintain awareness of and support for your IPM program now that it
is established (and may be “old news”)? How has receiving a National Excellence
Award helped you to raise and sustain program awareness?
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OMB Control #: 2070-0200
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Program Results: Please provide documentation of the results your district has achieved
using its School IPM program. Note that there are no quantitative requirements for
success here; the intention in asking for documented results is to ensure that results are
being collected. Possible items to document can include pest sightings, pesticide
application changes, missed school days, asthma incidents, financial benefits, or any
other quantities that can indicate IPM progress. Please attach your documented results
to this application.
Program Communication: An effective communications strategy (both internal to the
school system and external to the broader community) is a critical component of an effective,
sustainable IPM program. In this section, describe how you communicate to your school
community your IPM program’s goals, outcomes, and improvements, paying particular
attention to how your communications have changed as your program has matured. It is also
important to describe how you have used effective communications to ensure continued
support for your program and whether you have provided assistance to other school systems
seeking to improve their IPM. If you have a written communication plan, please attach
it to this application.
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Narrative: Please use the space below to detail any aspects of your district’s Integrated
Pest Management program which you have not mentioned anywhere else in this
application.
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TABLE FOR CONNECTOR AWARD FROM IPM INSTITUTE
Respondent
Paperwork Activity
Category
Example: Gather
information
Example: Gather
information
1. Read instructions
2. Plan activities
3. Gather
information
4. Compile and
review
5. Complete and
submit paperwork
6. Store/Maintain
data
Description of Category
(Specific task performed)
Request information from
schools
Gather requested information
and submit to district
Read Application Guide and
application for relevant Tier.
Plan gathering of information
that will be submitted to EPA.
Canvass / Contact personnel
from schools within the
district to gather information
for application.
Assemble data, evaluate for
accuracy, appropriateness,
and completeness.
Complete all appropriate
application documents and
send to EPA.
File and maintain copies of
materials submitted to EPA.
Job Title and Number of
Employees Performing this
Task
Average Time (in hours)
Spent by Each Employee
on this Task
IPM Coordinator, 1
1.5
Administrative assistant, 4
5.0
Project coordinator
Director
Project coordinator
Director
0.15
0.15
0.15
0.15
Project coordinator
Director
2.0
0.0
Project coordinator
Director
6.0
0.5
Project coordinator
Director
4.0
0.5
Project coordinator
Director
0.25
0.0
OMB Control #: 2070-0200
Expiration Date: MM/DD/YYYY
School Integrated Pest Management Connector Award
The U.S. Environmental Protection Agency’s (EPA) School Integrated Pest Management (IPM)
National Connector Award is presented to individuals and organizations that have contributed to
the adoption and use of IPM policies in school districts at the community, state, region, or national
level. The Connector Award is one of five levels of IPM awards which the EPA presents to school
districts or individuals. To find out which level of recognition is the best fit for your district, visit
[insert website].
Recipients of the School IPM Connector Award will receive:
•
•
•
•
A “Connector for School IPM” certificate signed by an EPA official;
Recognition on EPA’s web site – [insert web site];
Access to topical webinars, trainings, events and recognition and mentoring opportunities;
Regular e-mail updates aimed at advancing your school IPM program.
Eligibility
For an individual or organization to receive the Connector Award, the individual or organization
must:
• Provide a detailed account of their actions contributing to school IPM, with documentation of
efforts to assess the results of those actions;
• Describe how they communicated with relevant educational entities (schools, school districts,
state boards of education, etc.) to facilitate their IPM efforts;
• Demonstrate how their efforts will result in sustainable changes;
• Provide documentation of an endorsement from at least one educational entity in order to
verify the significance of their activities.
How to Apply
Interested candidates should complete the attached application and submit the application by e-mail,
U.S. Mail, facsimile or special delivery services (Federal Express, United Parcel Services, etc.).
E-mail:
ATTN: [insert email]
Facsimile:
ATTN: [insert facsimile]
U.S. Mail (or Special Delivery):
ATTN: [inset mailing address]
Paperwork Reduction Action Notice: The public reporting and record keeping burden for this collection is estimated to average
about 14 hours per response, including the time for reviewing instructions, searching existing data sources, gathering and
maintaining the data needed, and completing and reviewing the collection of information. This is a voluntary collection. An
agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a
valid OMB Control Number. The OMB Control Number of this collection is 2070-0200. Send comments regarding this
burden estimate or any other aspect of this collection of information, including suggestions for reducing the burden, to
Director, Collection Strategies Division (Mail Code 2822T), U.S. Environmental Protection Agency, Washington, DC
20460. Include the OMS control number in any correspondence, but do not submit the form or report to this address. The
form should be submitted in accordance with the instructions for the form.
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The application is a fill-in form, which will allow you to save what you have filled in on your
computer and submit it electronically via e-mail.
Applications for the Connector Award for a given year should be submitted by November 1st.
Awardees will be selected by the following January. For specific questions, contact the School IPM
Awards Coordinator at [insert contact information].
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Guidance for Completing the Connector Application
Clarification of the terms used in the attached application, guidance about how to get started with
IPM in your school district, and an IPM self-assessment checklist can be found at [insert
website].
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Contact Information
Please provide all of the information requested in the table below. If you are submitting this
application on behalf of an organization, please provide the organization’s information rather than
your own unless indicated otherwise.
The application is a fill-in form, which will allow you to type your answers directly into the
form, save what you have filled in on your computer, and submit it electronically via e-mail.
Contact Information
Name (Individual or Organization)
Name of Key Contacts (if Organization)
Title
Department
Address
City, State, Zip Code
Telephone
Fax Number
E-mail Address
Contact Information of Person Providing Endorsement
Name
Title
Organization
E-mail Address
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Your Contributions to School IPM
IPM Actions: Please provide a summary of your (or your organization’s) efforts contributing to
the adoption, implementation, and/or improvement of IPM practices in the educational setting.
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Results: Please describe how you or your organization measured the results of your efforts. Note
that the nature of such results will vary widely depending on the nature of the actions taken.
Please attach any relevant results to this application.
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Communication: Please describe how you or your organization communicated with educational
entities (schools, school districts, state boards of education, etc.) and other community members
as part of your efforts toward advancing School IPM. If you have a written communication
plan, please attach it to this application.
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Sustainability: Please describe how you or your organization has ensured or will ensure that the
changes resulting from your efforts will be sustained in the future, or how you or your
organization has maintained or will maintain your efforts in the future. If you have a written
sustainability plan, please attach it to this application.
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Endorsement: Please provide documentation of an endorsement from an educational entity
involved with your efforts that verifies the significance of your IPM activities. This endorsement
can come from any level of the educational system, but it should match the general level of your
activities; if your work mostly was with individual schools or districts, an endorsement could
come from a principal or superintendent, but if you worked on state policy issues, the
endorsement should come from a state official or entity. The endorsement should be no more
than one page single-spaced and should be placed on official letterhead. Please attach your
endorsement to this application.
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| File Type | application/pdf |
| Author | ltanner |
| File Modified | 2020-05-13 |
| File Created | 2020-05-13 |