Clean Indoor Air Act Complaint Form

Public Health

What would you like to do?

Select your language(elige tu idioma):

Date of the violation: *	Required
Time of the violation:
Facility name: *	A facility name is required
Facility address: *	A facility address is required
Facility city or town: *	A facility city or town is required
Where in the building was the smoking or electronic smoking device use observed?
Was there other evidence of smoking activity, i.e.: ashtrays?
Other details:
Your name:
Anonymous
Your phone:
Your e-mail address:

* Required