Smoking/Vaping Notification Form

Reporting school tobacco/vaping/cannabis offences enables Lambton Public Health to provide early and progressive enforcement of the Smoke-Free Ontario Act, 2017. An Enforcement Officer will respond to offence notifications as soon as possible. Please provide as much information as possible below. All information is private and confidential.

We appreciate your continued efforts to work with us to prevent youth from using tobacco and vapour products and to ensure a safer and healthier school environment. For non-enforcement related inquiries, please contact tobaccofree@county-lambton.on.ca

School:(Required)

Student Name:(Required)

Date of Birth:(Required)

Age:(Required)

Name of Parent/Guardian(Required)

First Last

Has the Parent/Guardian been notified?(Required)

Yes

Parent/Guardian Phone:(Required)

Input students information if over the age of 18

Address(Required)

Street Address City Province Postal Code

Type of Offence:(Required)

Smoking/Vaping/Smoking Cannabis

Holding Lit Tobacco or Cannabis/Holding Activated Vape Product

Supply/Share/Sell Tobacco/Vape Products to anyone under the age of of 19

Note: possession of tobacco or vapour products is not an offence under the SFOA, 2017.

Date of Offence:(Required)

Time of Offence:(Required)

Location of Offence:(Required)

Description of Offence:(Required)

Key Witness (Name/Position):(Required)

Other Key Witness (Name/Position):

Has the evidence been retrieved?(Required)

Yes

Please provide description of items(s) seized/observed:(Required)

Has the student been suspended?(Required)

Yes

Suspension end date:(Required)

Email of person submitting the form:(Required)

Personal information on this form is collected under the authority of the Health Protection and Promotion Act, 1983. Questions about this collection of personal information should be directed to the school principal, the Manager of the Health Promotion for Lambton Public Health 519-383-8331 or the Tobacco Enforcement Supervisor for Lambton Public Health at 519-383-8331 ext 3206.