Contact Champaign-Urbana Public Health District

Submit Smoking Complaint

Smoking complaint form
*Date incident occurred:	ex 04-05-2006
*Time incident occurred:	am pm
*Name of facility:
*Address of facility:
*City:
*State:
Zip code:
*Nature of complaint:
*"No Smoking" sign?	Yes No Not sure
*Outside ashtray?	Yes No Not sure
*Evidence of smoking?	Yes No Not sure
Evidence of smoking: If Yes, explain in detail:
Information about person smoking in facility
Name if known:
Description or any information about person
Name or description of server (bartender)
Date report was sent to police:	ex 04-05-2006
*Submitted by:
*Your address:
*City:
*State:
*Zip code:
*Your phone number:	ex 217-000-0000
*Did person stop smoking or leave facility?	Yes No Unknown/not applicable
*Was this reported to police?	Yes No Unknown/not applicable
*Was incident reported to facility staff?	Yes No Unknown/not applicable
*Was incident resolved?	Yes No Unknown/not applicable
Comments
*Name of CUPHD staff: for office use only
* denotes required fields. CUPHD staff: Please print before submitting.