Georgia Smokefree Air Act of 2005 - Complaint Form

Exposure to secondhand smoke is harmful to your health. The Georgia Smokefree Air Act protects the health of the population by prohibiting smoking inside most public areas and outlines specific guidelines for smoking in and around establishments that serve the public. For information on the Georgia Smokefree Air Act: http://dph.georgia.gov/smoke-free-enforcement

Please report violation to the Georgia Smokefree Air Act by completing this form.

Today's Date (required)

Form Info

Fax Complaint form to: Georgia Department of Public Health, Tobacco Use Prevention Program 404-657-4338.

COMPLAINT REPORTED BY:

Your Name (required)

Your Street Address (required)

City (required)

State (required)

Zip Code (required)

Telephone (required)

Your Email Address (required)

COMPLAINT INFORMATION

COMPLAINT INFORMATION:

Name of Establishment (required)

Address of Establishment (required)

Telephone for Establishment

Define Other

Date of violation (required)

Description of Violation (Check all that apply)