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Department of Public Health

Smoke-Free Air Complaint Form

Complete this form to report a potential violation of the Michigan Smoke-Free Air Law or the Ottawa County Smoke-Free Indoor Air Regulation.

Information marked with an asterisk (*) must be completed for the complaint to be investigated.

*1. Date of Potential Violation: Pick a date
2. Time of Potential Violation:
Please provide the following about the business or establishment where potential violation occurred:
*3. Business or Establishment Name:
*4. Business or Establishment Address:
*5. Business or Establishment City:
6. Business or Establishment Zip Code:
7. Business or Establishment Phone:
 
*Nature of Complaint
Please Note: Please make your selections in either section A (food service or bar) or section B (non-food service and non-bar)
*8. Please select where the potential violation occurred
8A. Observed the following potential violation within a food service or bar establishment: (You may choose more than one) Smoking inside establishment including but not limited to the dining area, bar area, restroom, or entryway
Ashtrays present
"No Smoking" signs not posted
Smoking in kitchen, break room or other non-public area
Smoking in an outdoor area intended for eating or drinking
Person in charge fails to inform violator(s) to stop smoking
OTHER: Please describe in detail below
8B. Observed the following potential violation within a non-food/non-bar establishment: (You may choose more than one) Smoking in any indoor area including but not limited to the general work area, a private office, break room, stairway, or retail area
Ashtrays present
"No Smoking" signs not posted
Smoking in an outdoor area within 25 feet of any entrance, operable window, ventilation intake system, or loading dock
Smoking in a shared company vehicle
OTHER: Please describe in detail below
*9. Please describe the potential violation in further detail in order to aid in the investigation:
*10. Did you attempt to resolve this issue prior to filing this complaint? Yes   No
If yes, describe in detail:
*11. Please read the statement and check the box: I understand that all of the information regarding this complaint becomes public record. I understand that my name, if included below, may be released only upon request. While my name and contact information is not required, it may aid in the investigation of my complaint.
 
(Optional)
Name:
Phone Number w/ Area Code:
Email: