Project DAWN Naloxone (Narcan ™) Kit Request Form

Please complete the following questions to request a free Naloxone (Narcan™) kit. Any OHIO residents/workers is eligible.

***The demographic questions are optional to help us determine the outcomes and impact of our program. You will NOT be denied supplies if you don't respond, however, this data is what helps our program remain free to Ohio residents.

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* 1. What is your affiliation/ confirm you are an OHIO resident. (Please note if you do not live in Ohio we are not able to send you naloxone. View out-of-state naloxone resources HERE)

I am a resident of OHIO

TCN Patient/Family

DeCoach Patient/Family

SafeTrade Syringe Services Program Participant

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* 2. Have you requested naloxone or fentanyl test strips from us before? (multiple requests are allowed)

Yes

Unsure/don't remember

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* 3. How did you learn about our mail order program?

GCPH website/social media

A friend/family member

SOAR Initiative Text Alerts

Another organization

A community event

Other (please specify)

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* 4. What is your current age?

14 or under

15-24

25-34

35-44

45-54

55-64

65+

Prefer not to say

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* 5. What gender do you most identify with?

Male

Female

Non-Binary/Gender Fluid

Prefer not to say

Not listed (please specify)

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* 6. What race(s)/ethnicities do you consider yourself to be? (Check all that apply)

White

Asian

Black/African American

Hispanic/Latino

Native Hawaiian/Pacific Islander

American Indian or Alaska Native

Prefer not to say

Other (please specify)

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* 7. Watch the following Narcan training video and confirm you have watched it: https://youtu.be/GtYl2y3iEgw

I have watched the training video

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* 8. Items included in kit: 2 doses 4mg Narcan Nasal Spray, 1 Face Shield, 2 Sterile Gloves, 1 Project DAWN informational booklet, 1 Project DAWN carrying bag.

I would like to request 1 kit

I would like to request 2 kits

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* 9. In which Ohio ZIP CODE do you live?

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* 10. In which Ohio COUNTY do you live?

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* 11. Have you used drugs in the last year (other than marijuana):

Yes

Prefer not to say

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* 12. Have you ever overdosed or witnessed an overdose?

Yes

Prefer not to say

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* 13. Is this the first Narcan kit you have received?

Yes

Prefer not to say

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* 14. If NO, what happened to your previous kit?

My kit was used on another person overdosing and they DID survive

My kit was used on another person overdosing and they DID NOT survive

Prefer not to say

The medication in my kit expired

Other (e.g. given away)

This is my first Narcan kit

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* 15. Mailing Address

Name/Alias

Address *

Address 2

City/Town *

State *

ZIP Code *

Email Address

Phone Number