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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