Public Health Communication Restriction Report Form
Use this form to report restrictions on public health messaging or communications. Please provide as much detail as possible to help us assess and address the issue.
Your Name
*
First Name
Last Name
Your Email Address
*
example@example.com
Organization (if applicable)
Date of Incident
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Location of Restriction (City, State/Region, Country)
*
Type of Communication Restriction
*
Please Select
Message blocked or censored
Channel access denied
Content delayed
Misinformation flagged
Other
Communication Channel Affected
*
Social media
News outlet (TV, radio, print)
Official website
Email
Other
Brief Description of Restriction
*
Impact on Public Health Messaging
Attach Supporting Evidence (optional)
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