COVID-19 Information Form                 [Washington County, Ohio]
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DO NOT SUBMIT PERSONAL MEDICAL INFORMATION. If you decide not to disclose your name and contact, please be sure to provided full details of your public health concern.
Name & Location of Establishment *
Establishment Contact Information
Please provide a brief description of your public health concern. *
Contact Information
This form is a government record and may be subject to the Freedom of Information Act.
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This form was created inside of Wcgov.org.