Are you a Kent, Ohio Resident? YES NO |
Date of Service: Month / Day / Year (numeric)
|
Please mark the type of service utilized: Vital Statistics Childhood Immunizations Complaint Investigation Environmental Health (Please check which program): Housing Food Safety Swimming Pools & Spa Animal Bites Tattoos & Body Piercing Other- Please List:
|
Please mark the quality of service you received: Excellent Good Average Needs Improvement Poor
|
Please mark the box that best describes our level of service:
|
Please mark which other services you would like us to provide: Travel Immunizations Primary Care Chronic Disease Education Smoking Cessation Program Maternal and Child Health Other- Please List:
Comments:
|
|
Thank you for your participation! |