Somerset County - Environmental Tobacco Smoke (ETS) Complaint Form




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Somerset County Health Department

Environmental Tobacco Smoke (ETS) Complaint Form

Involuntary or passive smoking is exposure to secondhand tobacco smoke. It is a mixture of exhaled mainstream smoke and sidestream smoke released from the smoldering cigarette or other smoking device and diluted with ambient air.. IT is also know as "environmental tobacco smoke" (ETS). Involuntary smoking involves inhaling carcinogens (cancer causing agents present in cigarettes) and other toxic components. Exposure to ETS causes lung cancer, other forms of cancer, has been linked to an increased risk for heart disease in nonsmokers and causes serious respiratory problems in children ETS remains a common serious public health threat that is entirely preventable by adopting and enforcing appropriate regulatory policies.

Name:
Address:
Phone:	Day
	Evening
Email:
Do you prefer to be contacted by	email
	mail
	phone

Please check appropriate selection:

Providing tobacco to minors
	Over the counter sale of tobacco to minor(s)
	Vending machine purchase of tobacco by minor(s)

Tobacco Use:
Type of facility: (please check one)

Government building(s)

Private worksite with less than 50 employees

Private worksite with more than 50 employees

School or grounds (public)

School or grounds (private)

Public Place

Residential dwelling(s)

Restaurant or restaurant/bar

Health Care facility

Child Care facility

Public Transportation

Elevator

Air or marine terminal

Fireworks plant or store

Other

State reason for complaint :

Expected outcome:

Did this occur in a designated "no-smoking zone"?	Yes	No
Was a sign posted to alert public of "no-smoking zone"?:	Yes	No

If this been reported in the past, where was complaint filed?

Please contact me to become involved in local tobacco control initiatives

Yes

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