Tobacco Laws

Incident Report Form

Note: Fields marked with an asterisk must be completed. Please note if you have more than one incident to report, please submit a separate form for each incident. All possible breaches reported will be investigated and if a breach is proven, on-the-spot fines or prosecutions will follow.

Location of Possible Breach
Location of possible breach: * (eg. XYZ Hotel)
Address: * (eg. 27 Smith Ave, Surfers Paradise)
Business phone: (If applicable)


Smoke-free Enclosed Places
Was the establishment? *	Liquor licensed Non-liquor licensed
Date of possible breach: *	(DD.MM.YYYY)
Time of possible breach: (If observed)	am pm
Description of smoker:
Description of situation in which possible breach occurred: *

Was the smoker directed to stop smoking?	Yes No Don't know
Licensed premises only: Was a no smoking sign on display at the entrance of the premises?	Yes No Don't know


Your Contact Details
Please provide your details in the event a Queensland Health Officer may need to contact you to clarify any information you provide.
Name:
Phone:
E-mail:
Your Details:	Employer Employee Patron/general public Other - Please specify: