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Champaign-Urbana Public Health District
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Submit A Smoking Complaint
Contact Information
201 W. Kenyon Rd., Champaign, IL 61820
201 W. Kenyon Rd., Champaign, IL 61820
Phone:
(217) 352-7961
Phone: (217) 352-7961
Fax: (217) 531-4336
Office hours: M-F 8:00 a.m. - 5:00 p.m.
Individual services hours vary,
check individual pages for hours.
How do I...
Contact CUPHD/Submit a complaint
Get a schedule of board meetings
Find out what days CUPHD is closed
Learn about freedom of information
Apply for a job/internship/volunteer position
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Maternal and Child Health
Wellness and Health Promotion
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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
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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.