Required fields are marked with asterisks (*)

Smoke-Free Ontario Act School Incident Report Form

The Smoke-Free Ontario Act, 2017, states that smoking and vaping is not allowed in public and private schools. This includes school grounds, and public areas within 20 metres of any point on the perimiter of school property. This Act is in effect at all times and applies to staff, students, parents, and visitors on school property including parking lots, inside vehicles, on sports fields and public areas within 20 metres from the perimeter of the school property.

Smoking refers to the smoking or holding of lighted tobacco or cannabis (includes medical).

Vaping refers to inhaling or exhaling vapour from an electronic cigarette/vape or holding an activated electronic cigarette/vape, whether or not the vapour contains nicotine or cannabis.

Please use this form to submit a violation of the Smoke-Free Ontario Act, 2017 that occurs on school property within Huron and Perth counties. Your report will be directed to a member of our enforcement team, and will be followed up by an enforcement officer.

Complaint submitted by:

Email address:

Phone number:

School:

Student Name:

Student's Age:

Student's date of birth:

Were parent(s)/guardian(s) notified:

Yes

Unsure

Method of parent/guardian notification:

Letter

Phone

E-mail

Other

Are you aware if this student has had any previous Smoke-Free Ontario Act violations?

Yes

Unsure

Has any previous action been taken against this student with regards to Smoke-Free Ontario Act violations?

Yes

Unsure

If so, what action was taken that you are aware of? (Check all that apply)

Verbal warning

Written warning

Suspension

Other

Student's address:

Parent/Guardian Name:

Parent/Guardian Phone Number:

Offence Information

Date of offence:

Time of offence:

Location of offence:

Product involved

Please select the product(s) involved and how being used (select all that apply):

Tobacco | smoking

Vaping products | vaping e-cigarette

Cannabis | smoking

Tobacco | holding lit

Vaping products | sell/supply vapour products

Cannabis | holding lit

Tobacco | supply/sell

Key Witness

Witness name:

Witness position:

Witness Report

Do you know the student personally?

Yes

If yes, how?

If no, how did you identify the student?

How far away from the student were you?

Where did the offence occur in relation to school property?

Could you see smoke or vapour from the product?

Yes

Are you certain that what you saw was smoke or vapour, not breath?

Yes

Could you smell smoke or vapour?

Yes

Could you smell other odours?

Yes

What was the explanation offered by the student?

Please provide a brief statement on the incident you are reporting.

Other Witnesses (if applicable)

Witness name:

Witness position:

Additional comments

Additional comments (if available):

By checking this box, I acknowledge that I have read, understand, and agree that the information provided in this form is correct.

Yes

If you require a copy of this information for your records, please print this page.

Disclaimer

Personal information on this form is collected under the authority of the Health Protection and Promotion Act, Smoke-Free Ontario Act, 2017, and the Education Act, and is for administrative use as determined by the Avon Maitland District School Board's Policy 356: Substance Abuse by Students under the Board's Jurisdiction, or the Huron Perth Catholic District School Board's Policy 3E:9 - Smoking and Vaping on Property under the Board's Jurisdiction.

Questions about the collection of personal information should be directed to the school prinicpal, the Director of Population Health of Huron Perth Public Health (1-888-221-2133), the Tobacco Program Public Health Manager of Huron Perth Public Health (1-888-221-2133) or the Superintendent of the respective school board.

Forms

Smoke-Free Ontario Act School Incident Report Form

Offence Information

Product involved

Key Witness

Witness Report

Other Witnesses (if applicable)

Additional comments

Disclaimer