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Summer Exemption Request for Farm Work for County Based Extension Agents
This form must be filled out per project and per location. You may only select one location per submission.
The committee will meet weekly to review submitted projects.
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* Indicates required question
Email
*
Your email
Project Leader First Name
*
Your answer
Project Leader Last Name
*
Your answer
Project Leader County
*
Your answer
Project Leader Job Title
*
Your answer
Project Leader Cell Phone Number
*
Your answer
Project Leader University ID
*
Your answer
Project Leader Unity ID
*
Your answer
Project Title
*
Your answer
Farm/Location Name
*
Your answer
County of Project
The county the farm is located in.
Your answer
Start Date
*
MM
/
DD
/
YYYY
End Date
*
MM
/
DD
/
YYYY
Description of work.
*
Must include: work schedule (including frequency, time of day, duration of each visit, etc, number of people per visit, work to be completed, and any other relevant information)
Your answer
What type of support from station staff is needed for this project?
*
Please provide a detailed explanation including type of support, equipment, personnel, facilities, etc
Your answer
Is this work Research or Extension?
*
Research
Extension
If this is an Extension project, is it replicated or non-replicated at that site?
*
Replicated
Non-replicated
N/A (Not Extension)
Funding Source, if any:
Your answer
Resources needed to complete this project (acres, # of animals, greenhouse space, etc)
*
Your answer
Justification of work
*
Why should this work continue during this global pandemic?
Your answer
Names of Individuals conducting work and contact info (employee ID, email, phone, position title) (classify as primary and then list their backup)
*
You must provide all of the information requested
Your answer
Do all the primary individuals completing the work have mandatory status or will mandatory status be requested immediately after approval?
*
Yes
No
Can this work be conducted without direct contact with individuals outside of those listed?
*
Yes
No
I have read the document linked below and agree to follow all sanitation and social distancing requirements here and provided by the CDC (whichever is more protective)
*
https://docs.google.com/document/d/10Ew7USdGyTBewWFsUrkvlD19iQJBXndhIE0-DdwssdQ/edit?usp=sharing
Yes
No
Describe your procedures for accomplishing proper sanitation and social distancing.
*
Your answer
A copy of your responses will be emailed to the address you provided.
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