Illinois Department Of Public Health - Smoke-Fee Illinois Act Complaint Form Page 3
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* Complaint Description (CHECK ALL THAT APPLY):
_____ Smoking in a public place or workplace where prohibited . . . . . . . . . . . . . . Section 15
_____ Smoking within 15 feet from entrances, exits, windows
that open, or ventilation intakes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Section 15
_____ Smoking in a vehicle owned, leased or operated by
the state or political subdivision of the state . . . . . . . . . . . . . . . . . . . . . . . Section 15
_____ Owner, operator, manager did not post “No Smoking” sign(s) . . . . . . . . Section 20 (a)
_____ “No Smoking” signs do not comply with the Act . . . . . . . . . . . . . . . . . . . Section 20 (a)
_____ “No Smoking” signs not posted at entrances . . . . . . . . . . . . . . . . . . . . . Section 20 (b)
_____ Ashtray and/or smoking receptacle where prohibited . . . . . . . . . . . . . . . Section 20 (c)
_____ Other (please specify):
Date violation occurred* _____________________________________________________________
Time violation occurred* _______________ ____ a.m. ____ p.m.
Is this your first complaint about this business?*
Yes _______ No _________
If no, how many previous complaints have you submitted about this business?* ________
Is this complaint regarding an*: Employee_______ Customer _______ Business Owner _______
(Check all that apply)
Additional detailed information about violation (optional):
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