Hospital / Retirement Home / Long-Term Care Facility Offence Notice Form

Front-line staff and administrators are encouraged to complete this form when infractions related to the Smoke-Free Ontario Act, 2017 or the Smoke and Vape-Free Outdoor Spaces By-Law are witnessed. This applies to hospital properties, retirement homes and long-term care facilities.

Once the form is submitted, a tobacco control officer will conduct an investigation.

For more information, email Public Health or contact the Environmental Health Duty Officer at 905-688-8248 ext. 7590.

Facility Offence Notice Form

General Information

Offender's name * Required

Date of birth * Required

Site name * Required

Site address * Required
Format example: 123 Main St.

City * Required

Postal code * Required
Format example: A1A 1A1

Offence Details

Date of occurrence * Required

Time of occurrence * Required
Format example: 11:15 a.m.

I witnessed the following offence (check all that apply) * Required
Smoking tobacco in a prohibited place
Holding lit tobacco in a prohibited place
Smoking cannabis in a prohibited place
Holding lit cannabis in a prohibited place
Using an electronic cigarette in a prohibited place

Describe what you saw and where it happened (for example, inside the common washroom or in their room) * Required

Were you able to smell tobacco or smoke? * Required
Yes No

Was vapour or smoke seen in the air? * Required
Yes No

Contact Information

Your name * Required

Your job position * Required

Phone number * Required
Format: XXX-XXX-XXXX

Notice of Collection

Any personal information or personal health information submitted will be collected, used, and disclosed, where applicable, by members of Regional staff according to the Municipal Freedom of Information and Protection of Privacy Act or the Personal Health Information Protection Act. Any information you share will only be used for the intended purpose for which it was provided.

For questions or comments about privacy practices, or for more information about the administration of the Municipal Freedom of Information and Protection of Privacy Act in Niagara Region programs, see Freedom of Information and Open Government.