[DC GOVERNMENT] Smoke-Free Workplaces

Smoke-Free Workplaces - Online Complaint Form

Please fill out this form to report violations of the Department of Health Functions Clarification

Amendment Act of 2006, effective April 3, 2006. The Department of Health will investigate

the complaint with the information you provide.

Please enter as much information as possible (items marked with a * are required

before we can investigate). Giving your name and contact information will enable

us to contact you if we need additional information to respond to your complaint,

but you may remain anonymous if you like.

After you have entered the required information, use the send button

at the bottom of the form to submit your form. To make a change, use the Start Over

button to erase all of the information entered.

If you have any questions or would like further information,

please call the DC Tobacco Control Program at (202) 671−5000.

Today’s Date

Business name

Phone Number

Untitled

Date of occurance

Date and Time of occurance

Description of Violation (check all that apply):

Briefly describe the violation below:

Which floor(s)? (Separate multiple floors by a comma)

Select location within the establishment

If other, describe below

Your name

Phone number (Day)

Phone number (Evening)

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