The version of the browser you are using is no longer supported. Please upgrade to a
Request edit access
Violations of UCM Tobacco Free Policy
The purpose of this anonymous form is to report "hot spots" or areas of consistent violations of UCM's Tobacco-Free policy. Response to violations will include monitoring the area, providing education on the policy, and initiating a more formal reporting process if individuals are consistently non-compliant.
Indicate the day(s) of observed violations
Check all that apply
Location of violation(s)
Please be as specific as possible
What type was being used?
Approximate time violations(s) were observed
Number of individuals observed at the location
List number of people you observed using tobacco. If you are not sure, do not count them in the total.
Did you approach the individual(s) and remind them of the tobacco-free policy?
If yes, did the individual(s) comply with the tobacco-free policy?
Not applicable. I did not approach the individual(s).
Please share any additional comments, questions, or suggestions below.
This information will be shared with the tobacco procedures committee to make a plan for how to address the hot spot.
If you would like a response from the Tobacco Procedures Committee, please provide your name and contact information.
Never submit passwords through Google Forms.
This form was created inside of University of Central Missouri.
Terms of Service