Submit A Smoking/Vaping Complaint

Last name *

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Date incident occurred *

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Time incident occurred *

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Name of facility *

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Address of facility *

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City *

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State *

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Zip code *

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Was the incident *

smoking

vaping/use of e-cigarettes

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Nature of complaint *

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No Smoking/Vaping sign? *

Yes

Not sure

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Outside ashtray? *

Yes

Not sure

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Evidence of smoking/vaping? *

Yes

Not sure

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Evidence of smoking/vaping (empty pods on ground, lingering scent, etc.) If Yes, explain in detail

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Information about person smoking/vaping in facility

Name if known

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Description or any information about person

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Name or description of server (bartender)

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Date report was sent to police

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Submitted by

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Your address

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City

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State

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Zip code

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Your phone number

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Did person stop smoking/vaping or leave facility? *

Yes

Unknown/not applicable

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Was this reported to police? *

Yes

Unknown/not applicable

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Was incident reported to facility staff? *

Yes

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Was incident resolved? *

Yes

Unknown/not applicable

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Comments

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Name of CUPHD staff: for office use only

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CUPHD staff: Please print before submitting.

Last name (optional):

Submit Smoking Complaint For Champaign County

Information about person smoking/vaping in facility