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.

First Name
(Recommended)
Your answer
Last Name
(Recommended)
Your answer
Organization you represent (if applicable)
Your answer
Age (optional)
Your answer
Gender (optional)
Your answer
Ethnicity (optional)
Your answer
Preferred method of contact
Phone number (including area code)
Your answer
Email Address (optional)
Your answer
Confirm email address
Your answer
Please write the name of the business or workplace where the alleged violation occurred
Your answer
Where is this located? (Please describe the village and approximate location)
Your answer
What type of establishment is this?
Approximately when did you see the potential violation?
Please include the approximate date and time.
MM
/
DD
/
YYYY
Time
:
Please describe your complaint
Check all that apply
Required
Please describe the location of the potential violation.
Check all that apply
Required
Please include any other details to the potential violation you saw here.
Your answer
Consent for submitting a complaint in confidence or public domain
Required
Required Consent
Required
Required Declaration
Required
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