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Service Request Intake Form

2. Would you like the Kent City Health Department to contact you?*

   1. The inspector may contact me for more information.
   2. I want to be contacted by the inspector with the results.
   3. Please do not contact me about this complaint.
   4. I would like to remain anonymous and will not automatically receive updates.

4. I. Person Reporting Information (Optional)

6. First Name

7. Last Name

9. Street Address

11. City

12. State

13. Zip Code

15. Phone Number

16. Email Address

18. II. Facility / Property Information (Location of Concern in Kent, Ohio)

20. List the Facility Name or Owner / Landlord and/or Resident(s)*

22. Street Address / Intersection (Within Kent, Ohio City Limits)*

24. Apartment / Room Number

26. Phone Number

28. III. Details of Service Request (Required Information)

30. Date & Time of Incident*
    Date & Time of Incident

    Date & Time of Incident

32. What is the problem? Please be specific. (Who, What, When, Why, How)*

34. How long has the problem been occurring?*

36. What is the exact location of the problem?*

    For example, "employee in the kitchen not wearing gloves" or "trash in the front yard."

38. Are there dogs or other safety hazards that the sanitarian needs to be aware of?*

    1. Yes
    2. No

40. If yes, please explain:

42. Have you notified the owner / manager of the issue?*

    1. Yes
    2. No

44. If yes, what was their response?

46. Do you have any photos or other media you would like to share?*

    1. Yes
    2. No

48. File 1

49. File 2

50. File 3

Leave This Blank:


52. Submit

* indicates a required field