Clean Indoor Act Complaint Form

Complaints

NOTE: This information is available under the Freedom of Information Act. Complaints are accepted anonymously.

Clean Indoor Air Act Complaint Form

You may file a complaint electronically or by mail. To file an electronic complaint please complete the following information and press submit. To file a complaint by mail, please download and print the PDF version of the complaint form and mail the completed form to: Arkansas Department of Health Environmental Health 4815 W. Markham, Slot 46 Little Rock, AR 72205-3867

Complaint reported by(Required)

First Last

Complainant Phone Number(Required)

Complainant Email(Required)

Complainant Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Date of Occurrence(Required)

Time of Occurrence(Required)

Name of Establishment or Individual(Required)

Address of Establishment(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Type of Business(Required)

Other Type of Business

Description of Violation(Required)

Customer Smoking

Employee/Owner Smoking

Smoke infiltrating into non-smoking area

Person in charge fails to inform violator(s) to stop smoking

Smoking in enclosed area

Other Violation

Briefly describe the violation below(Required)

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Complaints

Clean Indoor Air Act Complaint Form

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