Clean Indoor Air Act
Event Reporting Form

INSTRUCTIONS

This form is to be used to notify the Department of Health of a Fundraiser or Facility at which smoking will occur under the provision for Act 27 of 2008, from the Pennsylvania Clean Indoor Air Act. This report is not mandatory. The Department of Health (DOH) recommends that the report be filed in order to allow the DOH to provide assistance with compliance.

The Department of Health (DOH) would appreciate notification of an event at least thirty (30) days prior to the event. This allows adequate time for the DOH to send acknowledgement of the event. This form can be completed electronically by tabbing from field to field and entering the required information. Once you have completed the form you can click the ‘Submit’ button. 

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 1-877-835-9535. Click here to learn more.
 
Section:I
Type of Event:

(one event per calendar year)
or

(up to six (6) events per calendar year) *
Business/Organization Name: *
Identification Type:
EIN: * '999999999'
Organizer's Name: *
Address: *
City: *
State:      Zip Code: - *
County: *
Phone: ()- *