Please help us serve you better by telling us a little about yourself and your interests/needs:
Basic Contact Information |
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| * Last name |
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| * I prefer to be contacted by: |
Phone
E-mail
Postal Mail |
Phone:
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| Best day and time to call: |
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E-mail:
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| Mailing Address: |
Address: |
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Address: |
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City: |
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State: |
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Zip: |
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County:
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I am a: |
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Farmer |
Farm Address (if different from above): |
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Address: |
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Address: |
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City: |
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State: |
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Zip: |
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Commodities grown:
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Fisher |
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Forester |
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Agribusiness Representative |
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Agricultural Educator |
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Agricultural Engineer |
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Agricultural Health & Safety Professional |
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Cooperative Extension Agent |
What county? |
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Elected Official |
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Farm Worker |
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Health Care Provider |
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Media Representative |
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Student - High School |
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Student - College or Graduate |
Seeking degree in: |
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School or University: |
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Other occupation (please specify): |
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What do you need? |
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Equipment safety demonstration |
To be added to the AgriSafe list serve (recommended for farmers, fishers, forresters, agribusiness reps) |
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preferred delivery:
US mail
E-mail |
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General Information |
To be added to the AgrAbility list serve |
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preferred delivery:
US mail
E-mail |
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Medical clearance |
To receive Inside Agromedicine newsletter: |
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preferred delivery:
US mail
E-mail |
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Personal protective equipment (selection, fit, purchase) |
To be added to the Agromedicine list serve (recommended for researchers) |
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preferred delivery:
US mail
E-mail |
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Presentations |
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Safety Inspection for farm/ equipment safety |
Training |
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Other (please specify): |
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What topics are relevant to your request? |
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Aging farmers, fishers, or foresters |
Agritourism |
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Aquaculture |
ATV safety |
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Child and Youth Health & Safety |
Emergency pre-planning |
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Farm equipment/ Motor vehicle Safety |
First-on Scene in an emergency |
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Fishing safety |
Grain bin safety |
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Green Tobacco Sickness |
Hearing |
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Heat stress |
Individuals farming, logging, or fishing with a disability |
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Livestock safety |
Logging safety |
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Migrant and Seasonal Farm workers |
Personal Protective Equipment (i.e., gloves, respirators, chemical resistant clothing, eye protection) |
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Pesticide exposure safety |
Poultry handling safety |
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PTO safety |
Respiratory health |
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Safety training in Spanish |
Sun & skin care |
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Tractor safety |
Vision |
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Zoonotic disease (animal to human disease) |
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Other farm machinery safety (please specify): |
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Other (please specify): |
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What programs are you interested in receiving assistance or information from? |
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AgriSafe (agricultural health screenings and personal protective equipment) |
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AgrAbility (services for farmers, farm workers and their families with chronic conditions and disabilities) |
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Certified Safe Farm (on farm safety audit) (available in limited areas) |
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Child Health & Safety in Agritourism |
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Logging |
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Risk Mitigation Measure for Soil Fumigants (includes education, assistance with medical clearance, respirator fit testing, and personal protective equipment) |
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Other (please specify): |
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Are you interested in being a part of the North Carolina Agromedicine Institute by: |
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Contributing to the NC Agromedicine Funds at ECU or NC State University |
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Telling others about the NC Agromedicine Institute |
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Volunteering at the Institute |
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Volunteering at Outreach/ Education Events |
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Participating in Board of Partners Meetings |
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Attending outreach/ education events |
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Hosting an Ag Health & Safety event in collaboration with the Institute |
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Requesting an Institute member from our Speakers Bureau to present |
How did you hear about us? |
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An event I attended |
Which event? |
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Word of mouth |
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Website |
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Facebook |
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Twitter |
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Newspaper |
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Other (please specify) |
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| Additional Comments: |
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