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CHAMPAIGN URBANA PUBLIC HEALTH DISTRICT
Our mission:
To improve the health, safety and
well-being of the community through prevention, education, collaboration,
and regulation.
About CUPHD
Maternal and Child Health Dental Health Environmental Health Infectious Disease Prevention & Mgmt. Wellness and Health Promotion

Submit A Smoking Complaint

* Date incident occurred: Select a different date ex 04-05-2006
* 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: Select a different date 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.