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2. Are you a Kent, Ohio resident?

   1. Yes
   2. No
4. Date of Service
   Date of Service
6. Please mark the type of service utilized.

   1. Immunizations
   2. Service Request Investigation
   3. Environmental Health
   4. Vital Statistics
   5. Other
8. Which Environmental Health program?

   1. Animal Bites
   2. Food Safety
   3. Housing
   4. Swimming Pools and Spas
   5. Tattoos and Body Piercing
10. If other, please list.
12. Please mark the quality of service you received.

    1. Excellent
    2. Good
    3. Average

    1. Needs Improvement
    2. Poor
14. Please mark the boxes that best describe our level of service.
16. Courtesy of Staff

    1. Excellent
    2. Good
    3. Average

    1. Needs Improvement
    2. Not Applicable
18. Facility

    1. Excellent
    2. Good
    3. Average

    1. Needs Improvement
    2. Not Applicable
20. Office Hours

    1. Excellent
    2. Good
    3. Average

    1. Needs Improvement
    2. Not Applicable
22. Phone Service

    1. Excellent
    2. Good
    3. Average

    1. Needs Improvement
    2. Not Applicable
24. Wait Time

    1. Excellent
    2. Good
    3. Average

    1. Needs Improvement
    2. Not Applicable
26. Please mark which other services you would like us to provide.

    1. Chronic Disease Education
    2. Maternal and Child Health
    3. Primary Care
    4. Smoking Cessation Program
    5. Travel Immunizations
    6. Other
28. If other, please list.
30. Comments
Leave This Blank:


32. Submit

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