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Queensland Government
Link to Queensland Government (www.qld.gov.au)
 
Queensland Health

Incident Report Form

Smoke free Outdoor Places

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. Main Beach)
Address: * 
(eg. Surfers Paradise)
Business phone:
(If applicable)
 
Smoke-free Outdoor Places
Select location:*


Building Entrance
Children's playground equipment
Major sports facility
Patrolled beach area
Prescribed outdoor swimming area
Date of possible breach:*  (DD.MM.YYYY)
Time of possible breach:
(If observed)
Description of situation in which possible breach occurred:*
   
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:

   
 
   

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Last Updated: 13 March 2009
Last Reviewed: 13 March 2009