Request for Access to Jeffery Hall Last Name: * First Name: * E-mail: * Emerg. Phone Contact: * Position: * - Select -StaffFacultyGrad StudentPost-Doc Type of Access: * - Select -Intermittent access to develop courses for remote deliveryPriority Timeline 1 ResearchPriority Timeline 2 ResearchCollecting Data to Continue Remote WorkExtenuating Circumstances (Graduate Students, Postdoctoral Fellows)Extenuating Circumstances (Faculty, Staff)Critical Graduate Student Exams Date(s) and Time(s) of work you request to schedule in Jeffery Hall: * Building and room number where access is being requested: * Provide a rationale for requesting an exemption by briefly addressing why research cannot be completed remotely, is time sensitive, and/or of a critical nature. Please reference applicable points in the priority 1 and 2 research timelines or the need to prepare course materials for Fall remote delivery in your rationale. Rationale for Requesting: * Describe plans to implement Queen’s COVID-19 related public health measures (i.e., physical distancing, disinfection, PPE usage, etc): * I have read and agree to abide by the guidelines in the "Return to Campus Plan for Jeffery Hall": * - Select -YesNo I agree to complete the "COVID-19 Self Assessment Questionnaire" prior to each visit to Jeffery, and if I answer ‘yes’ to any of the questions I will not go to Jeffery Hall and will follow the recommendations provided on the form. * - Select -YesNo CAPTCHAThis question is for testing whether or not you are a human visitor and to prevent automated spam submissions.
