Clean Indoor Air Act
Violation Report Form

INSTRUCTIONS

This form is to be used for filing a complaint regarding a potential violation of the Pennsylvania Clean Indoor Air Act, 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.

This form is to be used to report the following potential violations:
  • The owner, operator or manager of the premises may be penalized for failing to post proper signage
  • The owner, operator or manager of the premises may be penalized for allowing smoking where it is prohibited
This form can be completed electronically by tabbing from field to field and entering the required information. Describe what you observed in as much detail as you can. If the possible violation(s) you describe are not all in one area, identify the location of each possible violation individually on separate forms. Once you have completed the form you can click the ‘Submit’ button.

If you are uncertain about how or where to submit the Form, or would like more information, call the Pennsylvania Department of Health (DOH) at (717) 783-6600. Click here to learn more.

The DOH will review violation reports and submit to the appropriate law enforcement agency. The information provided including your contact information will be kept confidential.
Violation Information :
Name of Place Where Violation Occured: *
Name of Business Owner (if known):
Street Address: *
City: *
State:    Zip Code: -
Phone (If Available): ()-
County Name: *
Type Of Business: *
If Other (Specify):
Does the establishment serve Liquor?: *
                                        Hr      Min
Smoking Violation Date(Click on Calendar):       *
Type of Smoking Violation(Check in all that apply):  *




If Other (Specify):
Additional information or Comments:
Complainant Information:
Your Name: *
Address: *
City: *
State:   *    Zip Code:   *
County: *
Phone (If Available): ()- *
*
   
* Fields Required