Naloxone Request

Name
Address
In which Ohio county do you live?
How old are you?
What race(s) and ethnicity do you consider yourself? (check all that apply)
 White
 Black or African American
 Hispanic or Latino
 Asian or Asian American
 American Indian or Alaska Native
 Native Hawaiian or other Pacific Islander
 Other
What sex were you assigned at birth, on your original birth certificate?
Do you consider yourself to be transgender or non-binary?
If YES, do you consider yourself to be:
Do you have health insurance?
Intended use for naloxone (Narcan): (check all that apply)
 If I overdose
 If I see someone overdose
 If a friend or family member overdoses
 For location to have on hand
Have you...
 ever used intravenous (IV) drugs?
 ever been in a formal treatment program (other than AA NA or other pee support groups)?
 been released from an inpatient treatment facility within the past 30 days?
 been released from a jail or correctional facility within the past 30 days?
 ever overdosed?
 None of the above
Is this the first naloxone (Narcan) kit you have received?
How many times have you witnessed someone overdosing?
How many times have you administered (used) Naloxone on someone overdosing?

Please watch the Naloxone Training Video https://youtu.be/dBF0ovVWPYc

I confirm with the checkbox below that I have watched the video.
Email address