Champaign-Urbana Public Health District

* Last name:
* Date incident occurred:
* Time incident occurred:   a.m. p.m.
* Name of facility:
* Address of facility:
* City:
* State:
Zip code:
* Was the incident smoking
vaping/use of e-cigarettes
* Nature of complaint:
* "No Smoking/Vaping" sign? Yes No Not sure
* Outside ashtray? Yes No Not sure
* Evidence of smoking/vaping? Yes No Not sure
Evidence of smoking/vaping (empty pods on ground, lingering scent, etc.) If Yes, explain in detail:
Information about person smoking/vaping 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/vaping 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
Name of CUPHD staff:
for office use only
* denotes required fields.
CUPHD staff: Please print before submitting.

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