Smoke-Free Air Act Violation Reports
Local law enforcement may investigate complaints about alleged violations of the Smokefree Air Act. The Division of Public Health/ Bureau of Environmental Health (DPH/BEH), or an authorized designee, may notify the proprietor of the public place or place of employment or coordinate a site visit after receipt of a complaint.
When filling out this form, required fields are indicated by a red asterisk (*). It is important to note that BEH is impaired in its ability to immediately address the alleged violations contained in anonymous complaints because further investigation is required. As such, BEH strongly suggests that complaints are submitted with contact information.
If you are having trouble filling out this form, please call 323-QUIT.
NOTE: Please file complaints within 10 days of observing potential violation(s) to facilitate a timely investigation.
Organization you represent (if applicable)
Preferred method of contact
I do not wish to be contacted and understand this may reduce the likelihood that my complaint is resolved.
Phone number (including area code)
Email Address (optional)
Confirm email address
Please write the name of the business or workplace where the alleged violation occurred
Where is this located? (Please describe the village and approximate location)
What type of establishment is this?
Gallery, library, theater or museum
Professional office or bank
Hotel or motel
Health care facility
Child care or adult day care facility
Common area of an apartment building or condominium
Bus or taxi
Supermarket or other retail store
Government building or building used for a government purpose
Sports arena or enclosed place of outdoor arena
Approximately when did you see the potential violation?
Please include the approximate date and time.
Please describe your complaint
Check all that apply
Smoking in prohibited area
Evidence of smoking in prohibited area (i.e. ashes, cigarette butts)
Ashtray(s) present in a prohibited area
Signs not posted
Smoke infiltrating into area where smoking is prohibited
Please describe the location of the potential violation.
Check all that apply
General work area
Within 25 ft of an entrance to a non-smoking area
Please include any other details to the potential violation you saw here.
Consent for submitting a complaint in confidence or public domain
I understand that the information regarding the date, time, location, and circumstances of my complaint are public record. I DO NOT consent to the release of my name to the public at this time.
I understand the information regarding the date, time, location and circumstances of my complaint are public record. I DO CONSENT to the release of my name in the public record.
I understand that my name may be released to the business owner in the event an enforcement action is pursued against this business.
I declare, under penalty of perjury, that all information I have provided in this complaint is true, correct, and complete to the best of my knowledge.
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