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UICAA Complaint Form
The Utah Indoor Clean Air Act (UICAA) is intended to protect community members from the dangers of secondhand smoke exposure.
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Name of establishment
Your answer
Address of establishment (include street and city)
Your answer
Date of violation
MM
/
DD
/
YYYY
Time of violation
Time
:
AM
PM
Description of violation
Your answer
Name of person reporting
Your answer
Phone number of person reporting
Your answer
Email of person reporting
Your answer
Can we contact person reporting for follow-up?
Yes, phone
Yes, email
Yes, either phone or email
No
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This form was created inside of Southwest Utah Public Health Department.
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