Certificate of Training Form

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This is to certify that

 __________________________________________________________________________________________________________
(Name)                                                                        (Date of Birth)


 __________________________________________________________________________________________________________
(Address)                                                                     (ZIP Code)

is 14 years of age or more and has successfully completed the ________________________________________________________
                                                                      (4-H or Vocational Agriculture)
training program and examination in:

                               (Check one)                   Tractor Operation
                                                             ✔


                                                             Tractor and Machinery Operation

as specified by the U.S. Department of Labor in the Agricultural Hazardous Occupation Order (Subpart E-1 of
29 CFR, Part 570) pertaining to the employment of youth under 16 years of age.

Certifying Authority (Extension Agent or                                        Person who conducted the training program
Vocational Agricultural teacher only)

Signature: ____________________________________________                         Signature: _________________________________________

Date: ________________________________________________                          Date: _____________________________________________

To the Instructor

     1. The above youth, upon your completion of this certificate, is qualified to be employed as (a) a tractor operator as described in
         item 1 on page two; or (b) as both a tractor and machinery operator as described in items 1 and 2 on page two if certified for
         both tractor and machinery operation. This certificate is acceptable by the U.S. Department of Labor as proof of training.

     2. The above youth may not be employed in any of the occupations listed in items 3 through 11 on page two.

     3. The certificate does not certify training in adjustment of equipment or proficiency in operation, nor does it mean that the
         holder knows how to safely operate one particular make or model of tractor or machine.

     4. It is the responsibility of the employer to instruct the employee on the safe and proper operation of the equipment to be used.

     5. The U.S. Department of Labor requires employers to maintain close supervision where feasible, or, where not feasible, in
         work such as cultivating, the employers or their representatives check on each youth’s progress at least midmorning, noon,
         and midafternoon.

     6. Any accident that results in an injury to this person should be reported by the employer to the proper authority including the
         certifying authority who signed this certificate.

     7. This copy of the certificate should be retained in your file for further follow-up and reporting requirements.



                                                                         -1-                                                  Form WH-5
                                                                                                                      Rev. November 2012
Occupations in Agriculture Particularly Hazardous for the Employment of Children Below the Age of 16

Item (1) Operating a tractor of over 20 PTO horsepower, or connecting or disconnecting an implement or any of its parts to or from
         such a tractor.

Item (2) Operating or assisting to operate (including starting, stopping, adjusting, feeding, or any other activity involving physical
         contact associated with the operation) any of the following machines:
         (i) Corn picker, cotton picker, grain combine, hay mower, forage harvester, hay baler, potato digger, or mobile pea viner;
         (ii) Feed grinder, crop dryer, forage blower, auger conveyor, or the unloading mechanism of a nongravity-type self-
         unloading wagon or trailer; or
         (iii) Power post-hole digger, power post driver, or nonwalking type rotary tiller.

Item (3) Operating or assisting to operate (including starting, stopping, adjusting, feeding, or any other activity involving physical
         contact associated with the operation) any of the following machines:
         (i) Trencher or earthmoving equipment;
         (ii) Fork lift;
         (iii) Potato combine; or
         (iv) Power-driven circular, band, or chain saw.

Item (4) Working on a farm in a yard, pen, or stall occupied by a:
         (i) Bull, boar, or stud horse maintained for breeding purposes; or
         (ii) Sow with suckling pigs, or cow with newborn calf (with umbilical cord present)

Item (5) Felling, bucking, skidding, loading, or unloading timber with butt diameter of more than 6 inches.

Item (6) Working from a ladder or scaffold (painting, repairing, or building structures, pruning trees, picking fruit, etc.) at a height of
         over 20 feet.

Item (7) Driving a bus, truck, or automobile when transporting passengers, or riding on a tractor as a passenger or helper.

Item (8) Working inside:
         (i) A fruit, forage, or grain storage designed to retain an oxygen deficient or toxic atmosphere;
         (ii) An upright silo within 2 weeks after silage has been added or when a top unloading device is in operating position;
         (iii) A manure pit; or
         (iv) A horizontal silo while operating a tractor for packing purposes.

Item (9) Handling or applying (including cleaning or decontaminating equipment, disposal or return of empty containers, or serving as
          a flagman for aircraft applying) agricultural chemicals classified under the Federal Insecticide, Fungicide, and Rodenticide
          Act (7 U.S.C. 135 et seq.) as Category I of toxicity, identified by the word “poison” and the “skull and crossbones” on the
          label; or Category II of toxicity, identified by the word “warning” on the label;

Item (10) Handling or using a blasting agent, including but not limited to, dynamite, black powder, sensitized ammonium nitrate,
          blasting caps, and primer cord; or

Item (11) Transporting, transferring, or applying anhydrous ammonia.



                                                     Public Burden Statement
The Department of Labor estimates that it will take respondents an average of 1 minute to complete this collection of information,
including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and
completing and reviewing the collection of information. If you have any comments regarding this burden estimate or any other aspect
of this collection information, including suggestions for reducing this burden, send them to the Administrator, Wage and Hour
Division, U.S. Department of Labor, Room S-3502, 200 Constitution Avenue, NW, Washington, DC 20210. DO NOT SEND THE
COMPLETED FORM TO THIS OFFICE.


                                                                   -2-                                                       Form WH-5
                                                                                                                     Rev. November 2012