Staff Field Visit Tracking Form Please enable JavaScript in your browser to complete this form.Type of visit *Circuit RiderNon-Circuit RiderDate of visit *Was this outside of normal business hours?YesMode of Outreach *Field VisitPhone Meeting/CallVirtual Meeting/Video CallPublic MeetingPrivate MeetingEmail CorrespondenceMain staff contact *Brad SchideMike ForinoStacey VairoStefon DanczukRenee TribertJane MontanaroChris WigrenJordan SorensenKristen HopewoodAmelia MowerAnna FossiAdditional people on visitBrad SchideMike ForinoStacey VairoStefon DanczukRenee TribertJane MontanaroChris WigrenJordan SorensenKristen HopewoodAmelia MowerAnna FossiBoard MemberInternCounty *FairfieldHartfordLitchfieldMiddlesexNew HavenNew LondonTollandWindhamNAStreet NumberStreet NameTown *N/AAndoverAnsoniaAshfordAvonBarkhamstedBeacon FallsBerlinBethanyBethalBethlehemBloomfieldBoltonBozrahBranfordBridgeportBridgewaterBristolBrookfieldBrooklynBurlingtonCanaanCanterburyCantonChaplinCheshireChesterClintonColchesterColebrookColumbiaCornwallCoventryCromwellDanburyDarienDeep RiverDerbyDurhamEast GranbyEast HaddamEast HamptonEast HartfordEast HavenEast LymeEast WindsorEastfordEastonEllingtonEnfieldEssexFairfieldFarmingtonFranklinGlastonburyGoshenGranbyGreenwichGriswoldGrotonGuilfordHaddamHamdenHamptonHartfordHartlandHarwintonHebronKentKillinglyKillingworthLebanonLedyardLisbonLitchfieldLymeMadisonManchesterMansfieldMarlboroughMeridenMiddleburyMiddlefieldMiddletownMilfordMonroeMontvilleMorrisNaugatuckNew BritainNew CanaanNew FairfieldNew HartfordNew HavenNew LondonNew MilfordNewingtonNewtownNorfolkNorth BranfordNorth CanaanNorth HavenNorth StoningtonNorwalkNorwichOld LymeOld SaybrookOrangeOxfordPlainfieldPlainvillePlymouthPomfretPortlandPrestonProspectPutnamReddingRidgefieldRocky HillRoxburySalemSalisburyScotlandSeymourSharonSheltonShermanSimsburySomersSouth WindsorSouthburySouthingtonSpragueStaffordStamfordSterlingStoningtonStratfordSuffieldThomastonThompsonTollandTorringtonTrumbullUnionVernonVoluntownWallingfordWarrenWashingtonWaterburyWaterfordWatertownWest HartfordWest HavenWestbrookWestonWestportWethersfieldWillingtonWiltonWinchesterWindhamWindsorWindsor LocksWolcottWoodbridgeWoodburyWoodstockMultiple (please list below)List multiple towns if neededVillage or section of townHistoric Resource Type *Archaeological ResourceHouseReligiousLandscapeIndustrialState or MunicipalMartitimeCommercialAgriculturalNeighborhood/CommunityNon ApplicableArchaeological Resource TypePre-ContactPost-ContactReligious Resource TypeChurchSynagogueMosqueParish HouseChapelLandscape Resource TypeParkGardenNaturalCemeteryIndustrial Resource TypeMillWorker HousingWarehouseState or Municipal Resource TypeTown HallSchoolLibraryGrangeState-owned PropertyOtherCommercial Resourse TypeTheaterCommercial building/generalPrivate ClubAgricultural Resource TypeBarnFarmContemporary Name of SiteIf a homeowner visit, just input "private home"Historic Name of SitePrimary reason for visit/type of activity *FundingAdvocacyEducationServicesEasementsSpecial ProjectsFundingThe 1772 Foundation Matching GrantMaintenance & Repair GrantSHPO GrantsHomeowner Tax CreditDeveloper Tax CreditGeneralAdvocacyCommunity organizingCEPADemolition ThreatRedevelopmentRelationship buildingZoning or regulationsEvent planningEducationProgramHDC trainingPlanningProfessional DevelopmentSocial mediaServicesHistoric designation/evaluationResearch/surveyTACGeneral recommendations/preservation planningFundraisingEasementsSHPO EasementPreservation Connecticut EasementSpecial ProjectsCIFFresh Start WorxLGBTQSecondary reason for visit/type of activityFundingAdvocacyEducationServicesEasementsSpecial ProjectsFundingThe 1772 Foundation Matching GrantMaintenance & Repair GrantSHPO GrantsHomeowner Tax CreditDeveloper Tax CreditGeneralAdvocacyCommunity organizingCEPADemolition ThreatRedevelopmentRelationship buildingZoning or regulationsEvent planningEducationProgramHDC trainingPlanningProfessional DevelopmentSocial mediaServicesHistoric designation/evaluationResearch/surveyTACGeneral recommendations/preservation planningFundraisingEasementsSHPO EasementPreservation Connecticut EasementSpecial ProjectsCIFFresh Start WorxLGBTQOrganization Type *DeveloperHDCLibraryMunicipalityMuseum/cultural institution/historical societyAdvocacy group/Friends groupNon-profit developerPrivate homeownerReligiousSchoolState governmentOther nonprofit or private businessContact Person Full Name *Contact Person Association/TitleMailing AddressAddress Line 1Address Line 2City--- Select state ---AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeContact Person PhoneContact Person EmailOther:Estimated number of people in attendance *Brief summary of site visit/recommendations for next steps *Estimated capital needs (total need for site, if applicable)$0-50k$50k-250k$250k-500k$500k-1milOver $1 millionEstimated potential economic impact (through grants or tax credits, if applicable)$0-5k$5k-15k$15k-50k$50k-100k$100k-250kOver $250kPlease upload a photo of the site Drag & Drop Files, Choose Files to Upload Please upload a photo of the site Drag & Drop Files, Choose Files to Upload Please add additional photos to the shared drive in the designated town file.CommentSubmit
