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.
Sign in to Google to save your progress. Learn more
First Name
Last Name
Organization you represent (if applicable)
Age (optional)
Gender (optional)
Ethnicity (optional)
Preferred method of contact
Clear selection
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? *
Approximately when did you see the potential violation? *
Please include the approximate date and time.
Please describe your complaint *
Check all that apply
Please describe the location of the potential violation. *
Check all that apply
Please include any other details to the potential violation you saw here.
Consent for submitting a complaint in confidence or public domain *
Required Consent *
Required Declaration *
Clear form
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy