Naloxone Request

In which Ohio county do you live?
How old are you?
What race(s) and ethnicity do you consider yourself? (check all that apply)

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)

Have you...

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

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