| Are you a Kent, Ohio Resident? YES NO |
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Date of Service:
Month / Day / Year (numeric)
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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:
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Please mark the quality of service you received:
Excellent
Good
Average
Needs Improvement
Poor
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Please mark the box that best describes our level of service:
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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:
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| Thank you for your participation! |
