breathe easy ARKANSAS | General Info

Arkansas Department of Health
Arkansas Clean Indoor 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 Branch, 4815 W. Markham, Slot 46, Little Rock, AR 72205-3867.

Date:

Complaint Reported by:

Your Name:	or Anonymous
Your Street Address:
City:
County:
State:
Zip Code:
Phone: (XXXXXXXXXX)
Signature

Complaint Information

Date of Occurrence: (mm/dd/yyyy)*
Time of Occurrence: (XX:XX)*		AM PM

* Name of Establishment/Individual:
Street Address:
* City:
* County:
State:	AR
Zip Code:
Phone (Day) : (XXXXXXXXXX)

*Type of business:

Wholesale/retail Facility	Healthcare Facility	Food Related Facility
Recreational Facility	Office/Workplace	Educational Facility
Sporting Facility	Lodging Facility
Other:

*Description of violation (check all that apply):

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:

*Briefly describe the violation below:

* denotes required field

	Submit

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

Complaints are public information. By submitting a complaint, you may be required to testify to the violations witnessed. Please return the completed form to: Arkansas Department of Health, Environmental Health Branch, 4815 W. Markham, Slot 46, Little Rock, AR 72205-3867 or call 1-800-235-0002.