SmokefreeNY.org

New York State Smokefree Workplace Violation Form

Please fill out the form below to report a violation of New York State's smokefree workplace law. The information you provide will be automatically forwarded to the local health department in charge of enforcing the law where the violation took place.

^*COUNTY where violation took place:

^*Date and Time of Violation:

^*Date of Violation:
^*Time of Violation:	(include AM or PM)

^*Location of Violation:

^*Name of business:
^*Street Address:
^*City:
Zip:
Phone Number:

^*Type of Business:

If other, describe below:

^*Description of Violation (check all that apply):

Customer smoking	Employee(s) and/or Owner(s) smoking
Person-in-charge failed to inform violator(s) to stop smoking	Smokefree policy not posted/disseminated to employees
Ashtray present in smokefree area	NO SMOKING signs missing
Smoking allowed in smokefree area	Other (describe below)
Briefly describe the violation below:

^*Location within business where violation was observed:

Which floor(s)? (separate multiple floors by a comma):

If other, describe below:

^*Smokefree Violation Reported By:

^*Your name:

^*Phone number:

	(day)
	(evening)

E-mail address:

Street address:

City:

State:

Zip: