MUFL Action: Surveys

    

Mask Discrimination Survey


Question 1: Name?



Question 2: City / Town?



Question 3: State?



Question 4: Zip code?



Question 5: E-mail Address?



Question 6: Phone number?



Question 7: What is the name AND location of the business that denied your service or entry? *DUE TO THE VOLUME OF RESPONSES, WE CANNOT ADD BUSINESSES TO THE NAUGHTY LIST IF THE NAME AND CITY IS NOT PROVIDED.



Question 8: Approximate date and time of incident?



Question 9: Do you have a medical condition which prevents you from being able to medically tolerate the wearing of a mask?

Yes
No
Rather not say

Question 10: Please provide any additional information about the situation which may be helpful.