(A) This form is to be used for filing a complaint regarding a potential violation of the Pennsylvania Clean Indoor Air Act, being 35 P.S. §§ 637.1 et seq., referred to as the CIAA. The CIAA prohibits an individual from engaging in smoking in a public place, and requires business owners to prohibit smoking and post signs where required.
(B) This form is to be used to report the following potential violations:
(1) The owner, operator or manager of the premises may be penalized for failing to post proper signage; and
(2) The owner, operator or manager of the premises may be penalized for allowing smoking where it is prohibited.
(D) Describe what you have observed in as much detail as you can. Once the information is completely entered, you can either e-mail or by clicking on the “Submit by E-mail” button or save a copy and print the completed form by clicking the “Print Form” button for submission to the Department of Health at the address listed below.
(E) After completing the form on-line, the report can be mailed to:
Division of Tobacco Prevention and Control |
Attention: Clean Indoor Air Act |
Pennsylvania Department of Health |
Room 1032 Health and Welfare Building |
625 Forster Street |
Harrisburg, PA 17120-0701 |
(F) If you are uncertain about how or where to submit the report, or would like more information, call the Clean Indoor Air Help Line at 1-717-783-6600.
Clean Indoor Air Act (CIAA)/Violation Report Form Name of Place Where Violation Occurred: _________________________________ Name of Business Owner: ______________________________________________ Address: ___________________________________________________________ City: _________________________ State: _________________________ County: ___________________________ Zip: ____________________ Telephone Number: ______________________________ Does the establishment serve liquor? [ ] Yes [ ] No Smoking Violation Date: _____________________ Time: _____________ Type of Smoking Violation: [ ] Failure to post “No Smoking” signs in or near location [ ] Patron, Customer or Visitor Smoking on Premises [ ] Owner or Operator Smoking on Premises [ ] Employee or Worker Smoking on Premises [ ] Other Additional Information or Comments: ______________________________________ _____________________________________________________________________ |
Complaint Information (optional): Name: _____________________________________________________________ Address: ___________________________________________________________ City: _________________________ County: ________________________ State: ___________________________ Zip: ____________________ Telephone Number: __________________________________________________ [ ] I certify that the following statements made by me are true. |
(Res. 2008-022, passed 11-6-2008) Penalty, see § 33.99