Submit A Smoking Complaint

* Last name:
* Date incident occurred:
* Time incident occurred:	a.m. p.m.
* 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:
* 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.

Champaign-Urbana Public Health District