Smoke-Free Air Act Violation Reports

Dit bestand kan niet worden geopend, omdat JavaScript niet aanstaat in je browser. Zet JavaScript aan en laad het bestand opnieuw.

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)

Last Name

(Recommended)

Organization you represent (if applicable)

Age (optional)

Gender (optional)

Ethnicity (optional)

Preferred method of contact

Phone

I do not wish to be contacted and understand this may reduce the likelihood that my complaint is resolved.

Selectie wissen

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.

Datum

Tijd

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

Improper Signage

Smoke infiltrating into area where smoking is prohibited

Anders:

Verplicht

Please describe the location of the potential violation. *

Check all that apply

Bar area

Dining area

Break room/Cafeteria

Restroom

Hallway

Stairway/stairwell

Vehicle

Garage

Loading Dock

Elevator

Kitchen

Retail Area

General work area

Not Applicable

Within 25 ft of an entrance to a non-smoking area

Anders:

Verplicht

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.

Verplicht

Required Consent *

I understand that my name may be released to the business owner in the event an enforcement action is pursued against this business.

Verplicht

Required Declaration *

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.

Verplicht

Verzenden

Formulier wissen

Verzend nooit wachtwoorden via Google Formulieren.

Deze content is niet gemaakt of goedgekeurd door Google. - Servicevoorwaarden - Privacybeleid

Ziet dit formulier er verdacht uit? Rapport

Formulieren