Connect Ohio Community Anchor Institution Survey

Contact Information

20% of survey complete.

*Your name: *

*Facility name: *

*Address: *

Address 2:

*City/Town: *

*State: *

*ZIP/Postal Code: *

Email Address:

*Phone Number: *

Elementary, Middle, or High school

College, University, or Trade school

Library

Hospital, Emergency Room, or Medical care facility

Public safety facilities (including Police, Sheriff, and Fire Departments)

Other Government facility (please specify below)

Other Non-Government facility (please specify below)

Please specify here, if necessary