Clean Indoor Air & Tobacco Violation Report Form

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Clean Indoor Air & Tobacco Violation Report Form

Use this form to report violations to Colorado's Clean Indoor Air Act. Responses will be reviewed by staff of the Colorado Department of Public Health and Environment's Tobacco Program and forwarded to the appropriate local public health agency for a follow-up.

Today's Date *

YYYY

In what city and county did the incident occur? *

What type of complaint is this? *

Colorado Clean Indoor Air Act Violation

Multiunit housing complaint (apartments, condos, etc.)

Illegal tobacco sale

Other

Please describe the incident. *

Where did the incident occur? *

Bar or Restaurant

Multiunit Housing Facility

Retail Establishment

Workplace

Park or Trail

Other:

When did the incident occur? *

YYYY

Please provide the name and address of the location where the incident occurred (if applicable). *

Your first name (this information is only for the health agency to contact you and your information will not be shared): *

Your last name (this information is only for the health agency to contact you and your information will not be shared): *

Email (this information is only for the health agency to contact you and your information will not be shared): *

Phone number (this information is only for the health agency to contact you and your information will not be shared): *

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