CSU Tobacco Free Violation or Incident Report Form

Location violator(s) observed: *

Location violator(s) observed: Other... please be specific below

If choosing other for location above please be as specific as possible, i.e., by front door of Student Center, near side door of Main Classroom leading into the courtyard, etc.

Was the violator(s) a: *

(If choosing other, please provide any details you feel would help identify this person below.)

Approximate time of day violator(s) observed:

Hour

:

Minute

am

pm

Approximate date of day violator(s) observed:

Month

Day

Year

Number of violators observed at the location:

Description of violator(s):

Give as much information as possible to help identify the individual(s), i.e., male or female, approximate age, appeared to be a faculty, staff, student, or contractor (but not positive), clothing (include a uniform if pertinent, i.e. campus dining, construction worker, cleaning staff, etc.), glasses, hair color and style, facial hair, etc.

Did you approach the violator(s) and remind them of the Tobacco Free Campus policy?

Yes

No

Did the violator(s) comply in a respectful way?

Yes

No

If you know the violator's first and last name, please submit their name and any additional information or comments you feel would be helpful:

Form Completed By (optional, but appreciated):

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CSU Tobacco Free Violation or Incident Report Form

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