Tobacco Violation Report

It is everyone’s responsibility to help enforce our tobacco-free policy. If you see a violation occur, please inform the individual of the policy. If you do not feel comfortable doing that, you may report it by completing this form:

Email Address.: *

Date violator(s) observed:

Location violator(s) observed (be as specific as possible):

Time violator(s) observed (format 00:00 AM/PM) i.e. 08:57 AM:

Number of violators observed at location:

Description of violator(s). Give as much information as possible, e.g., male or female, clothing, glasses, hair color and style, facial hair, student, staff visitor, vendor:

Did you approach the violator(s) and remind them of the tobacco-free policy?:

Yes

No

If yes, did the violator(s) comply with the tobacco-free policy?:

Yes

No

Would like to receive a follow-up response?:

Yes

No

Additional Comments:

Leave this field blank: