Project Dawn Training Video (TCCHD)

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* 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

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* 2. Please watch the video in its entirety, and then certify that you have watched it by checking "Yes."

Yes

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* 3. Your Age: (Required)

Under 18

18-24

25-34

35-44

45-54

55-64

65+

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* 4. Which gender do you most identify with?

Male

Female

Prefer not to answer

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* 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

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* 6. In which Ohio zip code do you live?

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* 7. In which Ohio county do you live?

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* 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

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* 9. Is this the first Narcan Kit you recieved?

Yes

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* 10. If no, what happened to your previous kit?

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* 11. If the previous kit was used on a person that was overdosing, did that person survive? (Required)

Yes

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

Yes

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* 13. Have you used drugs in the last year other than Marijuana?

Yes

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* 14. How many Narcan Kits are you requesting? (Required)

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* 15. Please provide the following contact information. (Required)

Name

Address

City/Town

State

ZIP/Postal Code

Email Address

Phone Number

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* 16. Please watch the video in its entirety, and then indicate and certify that you have watched it by choosing "Yes."

Yes

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* 17. Your Age: (Required)

15 - 24

25 - 34

35 - 44

45 - 54

55 - 64

65 - 74

75+