This form is intended to provide documentation of abuse, harassment, and denial of accommodations for people experiencing Multiple Chemical Sensitivity (MCS). Sharing your experiences will help us to advocate for greater rights and support for people experiencing MCS.

Accommodations can be: fragrance-free environments, least-toxic product use (products suitable for you to have access to environments), healthy and appropriate renovation materials, no-smoking and no-vaping environments (all smoke, including from marijuana), fragrance-free health care access, fragrance-free health care personnel, fragrance-free services, etc.

If you have faced any form of stigma, abuse, harassment, or denial of appropriate accommodations we encourage you to fill out this form in order to help us advocate for appropriate accommodations and the human rights of people experiencing MCS. If you are unsure of the exact date an event occurred please estimate based on month and year.

Please share as much as you are comfortable with sharing.  

The sections on this form are as follows:
1. Personal Information
2. Denial of Accommodation Request
3. Stigma in the medical community  
4. Other experiences (other than formal denial of accommodation or challenges regarding medical care)
5. Concern about the INSPQ Report
6. Additional Information

Please fill out only the sections that are relevant to you

* We encourage you to complete the entire form below and assure you of confidentiality. All items marked with an asterisk must be filled out.