Illinois Department Of Public Health - Smoke-Fee Illinois Act Complaint Form

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State of Illinois
Illinois Department of Public Health
Smoke-free Illinois Act
COMPLAINT FORM
Complete this form to submit a complaint regarding a potential violation of the Smoke-free Illinois Act.
Information marked with an asterisk (*) must be completed in order for the complaint to be investigated.
Information entered in this complaint form, including your name, will be provided only to authorized
enforcement agencies so they have the necessary information to follow-up on complaints. Your
name will be kept confidential by these authorized enforcement agencies but, in certain situations in
which penalties may be applied, your name may be released to attorneys representing the parties in
this matter.
Note: The Smoke-free Illinois Act provides that no individual may be discriminated against in any
manner for exercising their rights under this law.
* CHECK THE FOLLOWING BOX TO SHOW THAT YOU UNDERSTAND THE INFORMATION IN
THIS COMPLAINT WILL BE RELEASED TO AUTHORIZED ENFORCEMENT AGENCIES.
Type or print legibly in blue or black ink and mail the completed form to:
Illinois Department of Public Health
Tobacco-Free Communities Program
535 W. Jefferson St., 2nd Floor
Springfield, IL 62761
CERTIFICATION: I certify that the following statements made by me are true.
STEP 1
Citizen Complaint Information
Name____________________________________________________________________________
Phone Number (_____)______________________________________________________________
Area Code
E-mail Address ____________________________________________________________________

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