Project DAWN Narcan Intake Form

To receive a Project DAWN Kit, 
1.)   Answer the questions and submit this Project DAWN Narcan Intake Form.
2.)  Make sure you watch the Project DAWN training video or participate in a Project DAWN training.
3.)  Call Tracy at 330-270-2855 ext 109 to arrange a time to pick up a kit. 
4.)  Kits will be picked up curbside at Mahoning County Public Health at 50 Westchester Drive, Austintown, OH 44515 at the designated pick up time.

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* Please enter today's date.

Date

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* What is your age (in years)?

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* What sex were you assigned at birth, on your original birth certificate?

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* Do you consider yourself to be transgender or non-binary?

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* If you answered yes to the above question, do you consider yourself to be:

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* What race(s) and ethnicity do you consider yourself? (check all that apply)

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* In which Ohio county do you live?

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* Do you have health insurance

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* What is your intended use for the Narcan? (check all that apply)

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* Have you ever used intravenous (IV) drugs?

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* Have you even been in a formal treatment program (other than AA, NA, or other peer support groups)?

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* Have you been released from an inpatient treatment facility within the past 30 days?

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* Have you been released from a jail or corrections facility within the past 30 days?

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* Have you ever overdosed?

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* Is this the first Narcan kit you have received?

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* If this is not your first kit, what happened to your previous kit?

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* How many times have you witnessed someone overdosing?

0 5 more than 10
Clear
i We adjusted the number you entered based on the slider’s scale.

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* How many times have you administered (used) Narcan on someone overdosing?

0 5 more than 10
Clear
i We adjusted the number you entered based on the slider’s scale.

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* I have watched the Project DAWN training video and understand the following: (check all that apply)

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* I, the Project DAWN participant, understand.... (check each of the boxes)

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* What is your name?

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* What is your address and phone number, so we may contact you when your kit expires?

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* How did you hear about our Project DAWN program?

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* For Mahoning County Public Health Use only:

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