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The NC Agromedicine Institute is a University of North Carolina Institute.

Member Universities:
East Carolina University
North Carolina State University
NC Agricultural & Technical State University
Request for Information

Agromedicine Contact Form

Please help us serve you better by telling us a little about yourself and your interests/needs:

* Required fields


Basic Contact Information

* First name:
* Last name
* I prefer to be contacted by: Phone E-mail Postal Mail
Best day and time to call:
Mailing Address: Address:





I am a:

Farmer Farm Address (if different from above):






Commodities grown:
Agribusiness Representative
Agricultural Educator
Agricultural Engineer
Agricultural Health & Safety Professional
Cooperative Extension Agent What county?
Elected Official
Farm Worker
Health Care Provider
Media Representative
Student - High School

Student - College or Graduate Seeking degree in:

School or University:
Other occupation (please specify):

What do you need?

Equipment safety demonstration To be added to the AgriSafe list serve (recommended for farmers, fishers, forresters, agribusiness reps)

preferred delivery:
US mail E-mail
General Information To be added to the AgrAbility list serve

preferred delivery:
US mail E-mail
Medical clearance To receive Inside Agromedicine newsletter:

preferred delivery:
US mail E-mail
Personal protective equipment (selection, fit, purchase) To be added to the Agromedicine list serve (recommended for researchers)

preferred delivery:
US mail E-mail

Safety Inspection for farm/ equipment safety Training
Other (please specify):

What topics are relevant to your request?

Aging farmers, fishers, or foresters Agritourism
Aquaculture ATV safety
Child and Youth Health & Safety Emergency pre-planning
Farm equipment/ Motor vehicle Safety First-on Scene in an emergency
Fishing safety Grain bin safety
Green Tobacco Sickness Hearing
Heat stress Individuals farming, logging, or fishing with a disability
Livestock safety Logging safety
Migrant and Seasonal Farm workers Personal Protective Equipment (i.e., gloves, respirators, chemical resistant clothing, eye protection)
Pesticide exposure safety Poultry handling safety
PTO safety Respiratory health
Safety training in Spanish Sun & skin care
Tractor safety Vision
Zoonotic disease (animal to human disease)  
Other farm machinery safety (please specify):
Other (please specify):

What programs are you interested in receiving assistance or information from?

AgriSafe (agricultural health screenings and personal protective equipment)
AgrAbility (services for farmers, farm workers and their families with chronic conditions and disabilities)
Certified Safe Farm (on farm safety audit) (available in limited areas)
Child Health & Safety in Agritourism
Risk Mitigation Measure for Soil Fumigants (includes education, assistance with medical clearance, respirator fit testing, and personal protective equipment)
Other (please specify):

Are you interested in being a part of the North Carolina Agromedicine Institute by:

Contributing to the NC Agromedicine Funds at ECU or NC State University
Telling others about the NC Agromedicine Institute
Volunteering at the Institute
Volunteering at Outreach/ Education Events
Participating in Board of Partners Meetings
Attending outreach/ education events
Hosting an Ag Health & Safety event in collaboration with the Institute
Requesting an Institute member from our Speakers Bureau to present

How did you hear about us?

An event I attended Which event?
Word of mouth
Other (please specify)
Additional Comments: