ACDHH Clear Mask Request Form

Use the form below to request your single-use (disposable after one time use) Clear Mask (PPE) from ACDHH. These masks have been donated for distribution to Arizona residents by the Maricopa County Board of Supervisors.

THIS PROGRAM IS ONLY AVAILABLE TO ARIZONA RESIDENTS. SUPPLIES LIMITED.

Please answer all questions to ensure your request is complete. We will use the e-mail address listed to contact you if we have further questions about your eligibility or delivery instructions. The masks are available only while supplies last, and are distributed on a first-come, first-serve basis.

To ensure masks are equally distributed, if you are requesting for school use, we ask that you utilize this resource as a last resort.

10 masks will be distributed per request.

If you have trouble using this form, please contact us via email at: info@acdhh.az.gov.

You may also contact us via telephone at the following numbers:

602-542-3323 V and 480-559-9441 VP

For DeafBlind individuals, or those with Combined Vision and Hearing Loss (CVHL) who need assistance in completing the form, please contact Julie Stylinski via email at: j.stylinski@acdhh.az.gov.

Question Title

* 1. Please enter your contact information below to receive clear masks. Please reply "N/A" to items which do not apply.

Name *

Business/Organization

Mailing Address (Must be an AZ Address) *

Apt/Suite No.

City/Town *

ZIP/Postal Code *

Email Address *

Phone Number *

Question Title

* 2. County of Address Listed Above Within the State of Arizona

Question Title

* 3. Type of Phone Number Provided Above

Video Phone

Caption Phone

Cellular Phone

Home Phone

Business/Organization

Question Title

* 4. Is this request for a business/organization or household?

Business/Organization

Household

Question Title

* 5. Which of the following best describes the individual(s) whom will be using the masks? Check all that apply.

Deaf

Hard of Hearing

DeafBlind

Combined Vision and Hearing Loss (CVHL)

Hearing

Medical Provider with Deaf/Hard of Hearing Patients

ASL Interpreter

ASL Interpreter Using Tactile Sign Language

CART Provider

SSP (Support Service Provider) for DeafBlind

Educator for the Deaf/Hard of Hearing

Other (please specify)

Question Title

* 6. Do you plan to use these masks yourself or for others who interact with you? Check all that apply.

I will wear the mask(s) myself.

I will provide the mask(s) to others I interact with, such as family members or healthcare providers.

Both

Other (please specify)

Question Title

* 7. PLEASE NOTE:
Clear masks being shipped as of November 2020 were donated to the public by the Maricopa County Board of Supervisors. The ACDHH is distributing them as a courtesy, was not involved in the purchasing or product selection process, and cannot verify the effectiveness of the masks. Please indicate below that you have read this statement by checking the acknowledgment box.

I acknowledge the statement above.