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Project Dawn Training Video (TCCHD)
1.
Project DAWN is a community-wide naloxone (also known as Narcan) distribution program. Naloxone is a medication that can be used to quickly reverse an overdose caused by an opioid drug. The program educates opioid users, their family members, their friends, or any community member on how to recognize the signs and symptoms of a drug overdose, call emergency medical services, perform rescue breathing, and administer naloxone/Narcan nasally.
No private information will be shared. If you have questions about this form, please contact the health department at 330-675-2489, or you can also email Tammi at tammi.krafft@co.trumbull.oh.us between the hours of 8:30 am to 4:00 pm.
To order a kit, to be mailed to your home, follow the steps listed below.
Steps:
1.) Watch the training video, and then certify that you have watched it.
2.) Answer the questions that follow.
3.) Provide your name, address, phone number, and email. (If all of the information is not provided, a kit will not mailed.)
4.) Submit the form.
Please indicate and certify that you have read this information by choosing "Yes" below.
Yes
No
2.
Please watch the video in its entirety, and then certify that you have watched it by checking "Yes."
Yes
No
3.
Your Age: (Required)
Under 18
18-24
25-34
35-44
45-54
55-64
65+
4.
Which gender do you most identify with?
Male
Female
Prefer not to answer
5.
What race (races) and ethnicity(ies) do you consider yourself? (Required)
American Indian or Alaska Native
Asian or Asian American
Black or African American
Hispanic or Latino
Middle Eastern or North African
Native Hawaiian or other Pacific Islander
White
Another race
6.
In which Ohio zip code do you live?
7.
In which Ohio county do you live?
8.
Please check the box and indicate if do or do not live on Ohio.
I do live in ohio
I do not live in Ohio
9.
Is this the first Narcan Kit you recieved?
Yes
No
10.
If no, what happened to your previous kit?
11.
If the previous kit was used on a person that was overdosing, did that person survive? (Required)
Yes
No
12.
Have you ever overdosed, or witnessed an overdose?
Yes
No
13.
Have you used drugs in the last year other than Marijuana?
Yes
No
14.
How many Narcan Kits are you requesting? (Required)
15.
Please provide the following contact information. (Required)
Name
Address
City/Town
State
ZIP/Postal Code
Email Address
Phone Number
16.
Please watch the video in its entirety, and then indicate and certify that you have watched it by choosing "Yes."
Yes
No
17.
Your Age: (Required)
15 - 24
25 - 34
35 - 44
45 - 54
55 - 64
65 - 74
75+
Current Progress,
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