Connect Ohio Community Anchor Institution Survey

Please provide the following information about yourself and your facility:(Required.)

*Your name:

*Facility name:

*Address:

Address 2:

*City/Town:

*State:

*ZIP/Postal Code:

Email Address:

*Phone Number:

Which of the following categories best describes your facility?(Required.)

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

Contact Information