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1. I have a complaint regarding (pick the most significant):

Lack of face coverings Lack of social distancing Lack of hygiene Business is exceeding capacity limits Sick employees working Lack of cleaning after a positive case in the workplace Lack of notification regarding a positive employee

2. I am:

Employee Employer Customer, client, patient or public Other

3. Type of business:

Arcade or other recreation Car dealership Close contact personal service (including massage, nail salon, hair salon, makeup, tattoo and tanning) Construction Fitness center or health club Indoor or outdoor event facility Laboratory Library Lodging (including hotels, motels, inns, bed and breakfast accommodations, and all other short-term residential rentals) Manufacturing Museum, cultural facility or guided tour Office space Place of worship Restaurant, bar, or social club Retail Sectors Not Otherwise Addressed Theater or performance venue Youth or adult amateur sport (including pools, fields, courts, rinks, tracks, gyms, and dance studios)

Business Name:

Business Street:

Business City:

Business State:

Owner First Name:

Owner Last Name:

Owner Email:

Owner Phone:

Your First Name:

Your Last Name:

Email:

Phone:

Note:

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