Get the free Secondhand Smoke Complaint Referral Form - mass

Secondhand Smoke Complaint Referral Form Please note that the information in the box below must be complete in order for the Massachusetts Department of Public Health to investigate this complaint.

How to fill out secondhand smoke complaint referral

How to fill out a secondhand smoke complaint referral:

1. Start by obtaining the necessary forms: Contact your local health department or relevant authority to inquire about the specific forms required for filing a secondhand smoke complaint referral. They will inform you about any specific documentation needed.
2. Provide your contact information: Fill out your personal details on the form, including your name, address, phone number, and email. This information is essential for the authorities to reach out to you and keep you updated regarding the complaint.
3. Describe the location of the issue: Clearly state the address or location where the secondhand smoke problem is occurring. Specify the building name, apartment number, or any other relevant details to ensure accuracy.
4. Provide information about the source of the smoke: Indicate the source of the secondhand smoke, such as neighboring apartments, public spaces, or workplace areas. Include details about the frequency and duration of the exposure, as well as any identifiable individuals involved.
5. Document instances and witnesses: If possible, record specific instances of secondhand smoke exposure, along with the dates and times they occurred. Additionally, provide the names and contact information of any witnesses who can support your claim.
6. Describe the health effects: Explain how the secondhand smoke is negatively affecting your health or the health of others living or working in the vicinity. List any symptoms experienced, such as respiratory issues, allergies, or other related health problems.
7. Attach any supporting evidence: If available, include any photographs, videos, or other evidence that can substantiate your complaint, such as cigarette butts, ashtrays, or signs of smoking in prohibited areas.
8. Sign and submit the complaint: Read the declaration statement carefully, and if you agree with its contents, sign and date the form. Make sure to follow any instructions provided regarding where and how to submit the complaint.

Who needs a secondhand smoke complaint referral?

Anyone who is being exposed to secondhand smoke in their living or working environment can request a secondhand smoke complaint referral. This includes residents in apartment buildings, employees in businesses, or individuals utilizing public spaces where smoking is prohibited. Filing a referral is especially beneficial for people who are experiencing adverse health effects due to secondhand smoke exposure and want to seek resolution to the problem.

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What is secondhand smoke complaint referral?

Secondhand smoke complaint referral is a process for reporting instances of secondhand smoke exposure in a public place or multi-unit housing.

Who is required to file secondhand smoke complaint referral?

Anyone who has been exposed to secondhand smoke and wishes to report the incident can file a complaint referral.

How to fill out secondhand smoke complaint referral?

To fill out a secondhand smoke complaint referral, one must provide details about the date, time, location, and nature of the exposure.

What is the purpose of secondhand smoke complaint referral?

The purpose of a secondhand smoke complaint referral is to document and address instances of secondhand smoke exposure in order to protect public health.

What information must be reported on secondhand smoke complaint referral?

The information reported on a secondhand smoke complaint referral should include details about the exposure incident, any health effects experienced, and contact information for follow-up.