Report any illegal activities that are occurring at retail locations in Utah of a tobacco, electronic cigarette, or nicotine product

Use the form to report any illegal activities that are occurring at retail locations in Utah of a tobacco, electronic cigarette, or nicotine product. This could include but is not limited:

Underage sale or distribution of a tobacco, electronic cigarette, or nicotine product

Sales of flavored electronic cigarette products in a General Tobacco Retailer (ie. Grocery stores, gas stations, etc.)

Which best describes you?

How did the illegal sale occur?

Approximate Date

Approximate Time

Description of product(s) purchased/sold (brand name, nicotine concentration level, etc)

How did the person pay for the product?
Photo of receipt
Other Documentation

How did you know this activity was occurring?

Are you willing to speak to a representative at Utah Department of Health or your Local Health
Department for more information?

Name (Optional)
Phone Number (Optional)
Email (Optional)
If you prefer not to give your Name, Phone, or Email, how may we contact you?

What is the age of the buyer?

Age of Buyer

Retailer Business Name
Retailer Physical Address
Street 1

Street 2

City

State/Region

Postal Code

Retailer Phone Number

Retailer Website Retailer Social Media Retailer Social Media Handle

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