Facility Positive Reporting

Facility Contact Name *

Facility Contact Phone Number *

Facility Contact Email Address *

Facility Name *

Facility Type * - Select -ManufacturingDistributionConstructionConsumer, Retail & ServicesGeneral Office EnvironmentSchools and DaycaresRestaurants and BarsPersonal Appearance and Beauty BusinessesOlder Adult Day CareAdult Day Support or Vocational Habitation ServicesEntertainment, Recreation, and GymsOther

Other Facility Type *

Facility Address *

Facility City *

Facility Zip Code *

Positive Name *

Positive Date of Birth *

Month MonthJanFebMarAprMayJunJulAugSepOctNovDec

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Year Year191019111912191319141915191619171918191919201921192219231924192519261927192819291930193119321933193419351936193719381939194019411942194319441945194619471948194919501951195219531954195519561957195819591960196119621963196419651966196719681969197019711972197319741975197619771978197919801981198219831984198519861987198819891990199119921993199419951996199719981999200020012002200320042005200620072008200920102011201220132014201520162017201820192020

Positive County of Residence * - Select -AdamsAllenAshlandAshtabulaAthensAuglaizeBelmontBrownButlerCarrollChampaignClarkClermontClintonColumbianaCoshoctonCrawfordCuyahogaDarkeDefianceDelawareErieFairfieldFayetteFranklinFultonGalliaGeaugaGreeneGuernseyHamiltonHancockHardinHarrisonHenryHighlandHockingHolmesHuronJacksonJeffersonKnoxLakeLawrenceLickingLoganLorainLucasMadisonMahoningMarionMedinaMeigsMercerMiamiMonroeMontgomeryMorganMorrowMuskingumNobleOttawaPauldingPerryPickawayPikePortagePreblePutnamRichlandRossSanduskySciotoSenecaShelbyStarkSummitTrumbullTuscarawasUnionVanWertVintonWarrenWashingtonWayneWilliamsWoodWyandot

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