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Service Request Intake Form

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

  2. I. Person Reporting Information (Optional)

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

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

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

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

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

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

  9. Leave This Blank: