Copy of UPDATED Weekly Ohio Department of Health Request for Information 032320

Facility Demographics

Please enter your facility's contact information below.

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* 1. Facility Name

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* 2. Facility Address

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* 3. In what county is your facility located?

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* 4. Facility type

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* 5. Contact Person's Name and Email Address

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* 6. Phone Number

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* 7. What is your facility's capacity?

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* 8. What is your facility's current census?

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* 9. How many open beds does your facility currently have?

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* 10. How many open private rooms does your facility currently have?