Page 1 of 2 Complainant Details Date the initial complaint was registered to Please describe the nature of your complaint, including how long the exposure to secondhand smoking/vaping aerosol has been happening: Describe the actions, if any, the has taken to remedy the complaint (i.e. segregating any smoking permitted areas): Does this business have a smoking policy? Yes No Don’t Know If yes, please attach a copy of the policy and procedure regarding smoking in the facility. Complainant Confidentiality: Confidentiality of the complainant shall be protected pursuant to RSA 155:74, II, as follows: (a) In accordance with RSA 91-A, all information contained in a complaint shall be furnished to the public on request, except that the complainant’s name shall not be supplied without express written approval of the complainant. Signature of complainant: Date: (Your complaint must be signed and dated in order to be formally investigated) For More Information NH Department of Health & Human Services, Division of Public Health Services, Tobacco Prevention and Cessation Program 800-852-3345, Ext. 6891 or (603) 271-6891 Submit this form by fax to (603) 271-5318 or by email to Page 2 of 2
Page 1 of 2 Complainant Details Date the initial complaint was registered to Please describe the nature of your complaint, including how long the exposure to secondhand smoking/vaping aerosol has been happening: Describe the actions, if any, the has taken to remedy the complaint (i.e. segregating any smoking permitted areas): Does this business have a smoking policy? Yes No Don’t Know If yes, please attach a copy of the policy and procedure regarding smoking in the facility. Complainant Confidentiality: Confidentiality of the complainant shall be protected pursuant to RSA 155:74, II, as follows: (a) In accordance with RSA 91-A, all information contained in a complaint shall be furnished to the public on request, except that the complainant’s name shall not be supplied without express written approval of the complainant. Signature of complainant: Date: (Your complaint must be signed and dated in order to be formally investigated) For More Information NH Department of Health & Human Services, Division of Public Health Services, Tobacco Prevention and Cessation Program 800-852-3345, Ext. 6891 or (603) 271-6891 Submit this form by fax to (603) 271-5318 or by email to Page 2 of 2
complaint.docx