Clean Indoor Air Act - N.Y.S. Public Health Law Article 13-E
File a Complaint: Smoking in Public

Please complete the form below to file a complaint regarding smoking in public. Try to provide the most accurate information you can. Any personal information you provide is kept strictly confidential and
will not be shared with any outside agencies or organizations.
Only violations in Rockland County will be addressed.
 
Date registering complaint: ex.(00/00/00)
 
1. Tell us about yourself: 

 Your Name:

 Your Contact Phone Number:

You wish to remain Anonymous [and you understand that the Health Dept. will not be able to contact you regarding this complaint.]
 
2. Tell us where the smoking occurred; check all that apply:
Smoking at a bar  
Smoking in a restaurant  
Smoking in an office  
Smoking in a recreational facility (please identify type:)
Other (please describe:)
 
3. Tell us about the establishment in question:
 Name of Establishment:
 Owner's or Manager's Name:
 Address:
 City:
 Zip Code:
 Phone  Number:
 
4. Tell us when the smoking occurred:
 Date:
 Day:
 Time:
 Do not remember exactly (please approximate):
 
5. Tell us what you observed regarding person(s) smoking; check all that apply:
  Patron or Customer smoking  
  Multiple Patrons or Customers smoking  
  Bartender smoking  
  Owner smoking  
  Manager smoking  
  Employee smoking  
  Multiple Employees smoking  
  Other person(s) smoking (please describe)
 
6. Tell us where ashes and cigarette butts were being deposited; check all that apply:
  In ashtrays  
  In beer bottles  
  In plastic cups with water  
  On the floor  
  Other
 
7. Tell us the circumstances:
  Persons were smoking at the bar  
  Persons were smoking at tables  
  Persons were smoking in the rest rooms  
  Persons were smoking in the office proper  
  Persons were smoking in public areas  
 "No Smoking" signs were posted
  Yes   No
 Persons in charge asked persons to stop smoking
  Yes   No
 You complained and the smoking stopped
  Yes   No
 You were told smoking was allowed
  Yes   No
 You were asked to leave the establishment
  Yes   No
 
8. Approximately how long were you present at the establishment?
  5 minutes or less
  5-15 minutes
  15 minutes-1/2 hour
  1/2 hour-1 hour
  1 hour or more
 
9. How often do you frequent this establishment?
  This was my first visit
  On a regular basis
  Infrequently
 
10. Please list any other comments you may have below: