Project Dawn - Mahoning County Public Health (Ver 3.5 Rev 3/1/2025) Survey

Project DAWN Intake Form

To receive a Project DAWN Narcan Kit (containing 2 doses of Narcan, protective gloves, and a barrier face shield) and/or Fentanyl Test Strips (FTS) or Xylazine Test Strips (XTS):

1.) You must have participated in a Project DAWN training or have watched the Project DAWN training video (a link to the video in contained in this intake form).

2.) Answer the questions and submit this Project DAWN Intake Form.

3. ) We can mail kits and/or FTS and XTS to residents of Mahoning County only (limit of only 2 kits mailed).

4.) If picking up your kit/FTS or XTS, you will receive a phone call or email stating that your intake form was received and when your kit/FTS or XTS will be ready for you. Your kit/FTS or XTS can be picked up in the Nursing Division at Mahoning County Public Health, 50 Westchester Drive, Austintown, OH 44515 between the hours of 8 am to 4:30 pm, Monday through Friday.

Would you like a Narcan kit? One Narcan kit contains 2 doses of Narcan, protective gloves, and a barrier face mask)?

No Narcan kit is requested.

1 Kit

2 kits

If more than 2 Narcan kits are requested, please indicate how many kits or boxes of Narcan only (one box contains 2 doses) are needed. Kits must be picked up at our office.

Would you like Fentanyl Test Strips (FTS)? FTS are small strips of paper that can detect the presence of fentanyl in different kinds of drugs and drug forms (pills, powder, and injectables). FTS can inform people about the presence of fentanyl so they can take steps to reduce their risk of overdose.

No FTS are requested

1 packet (5 strips)

2 packets (10 strips)

If requesting more than 10, please indicate how many packets of FTS requested. Each packet contains 5 strips.

Would you like Xylazine Test Strips (XTS)? XTS are small strips of paper that can detect the presence of xylazine in different kinds of drugs and drug forms (pills, powder, and injectables). XTS can inform people about the presence of xylazine so they can take steps to reduce their risk of overdose.

No XTS are requested

1 packet (5 strips)

2 packets (10 strips)

If requesting more than 10, please indicate how many packets of XTS requested. Each packet contains 5 strips.

In which Ohio county do you live?

Mahoning County

I do not live in Ohio

Prefer not to say

If you do not live in Mahoning County, please list the name of the Ohio County that you do live in.

Have you used drugs in the last year (other than marijuana)?(Required.)

Yes

Prefer not to say

Have you ever overdosed or witnessed an overdose?(Required.)

Yes

Prefer not to say

If requesting a Narcan kit, is this the first one you have received?(Required.)

N/A

Yes

Prefer not to say

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

My kit was used on me or another person who was overdosing, and I/they survived

My kit was used on another person who was overdosing, and they did not survive

The medication in my kit expired

Prefer not to say

Other (please specify)

I have watched the Project DAWN training video and understand the following: (check all that apply). Video can be found here.(Required.)

Risk Factors: Using opioids, having a previous overdose, lowered tolerance, mixing drugs, and other health conditions such as asthma, liver or kidney disease, heart disease or HIV/AIDS.

Signs of an overdose: Unresponsive; slow, shallow, or no breathing, choking, snoring, or gurgling sounds; blue, grey, or ashen lips and fingernails; pale or clammy face; slow or absent pulse; vomiting; or seizures.

Calling 9-1-1

Rescue Breathing (currently not recommended if it is a stranger)

Preparing the Narcan: Peel, Place, and Press

Administering Narcan with repeat administration in 2-5 minutes

Follow-up: placing in recovery position and staying with person overdosing

If the kit is used or expired, you can get a refill by contacting Mahoning County Public Health

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

that I have watched the training video or participated in a training.

the extreme importance or calling 911 in the event of an overdose and use of Narcan.

I confirm this by typing my name below

Please list your contact information so that we may mail your items or notify you when they are ready for pick up.(Required.)

Full Name

Street Address

City

State

Zip Code

Phone number

Email Address

Agency Name, if applicable

How would you prefer to be contacted?(Required.)

Phone call/voice message

How would you prefer to receive your Project DAWN kit?(Required.)

I will PICK UP at Mahoning County Public Health, 50 Westchester Drive, Austintown, 44515 between 8 AM and 4:30 PM Monday through Friday.

MAIL my kit to the address listed above (Mahoning County Residents ONLY)

If requesting Fentanyl Test Strips (FTS), I acknowledge and accept.... (please read and check each of the boxes)

n/a, I do not need FTS.

all responsibility and liability for possessing the FTS.

that a wide variety of substances can be laced with fentanyl. While it is advisable to test substances for fentanyl, there are no well researched, established recommendations on how to test drugs with test strips.

that there is a possibility that the FTS may not indicate the presence of fentanyl and that they are not guaranteed to detect all forms of fentanyl.

that I can overdose even if the FTS says there is no fentanyl in the heroin, cocaine, or other substance tested.

all responsibility and liability for any injury or death that could occur after ingesting any substance, whether they have been tested or not tested for fentanyl.

I confirm this by typing my name below:

If requesting Xylazine Test Strips (XTS), I acknowledge and accept.... (please read and check each of the boxes)

n/a, I do not need XTS.

all responsibility and liability for possessing the XTS.

that a wide variety of substances can be laced with xylazine. While it is advisable to test substances for xylazine, there are no well researched, established recommendations on how to test drugs with test strips.

that there is a possibility that the XTS may not indicate the presence of xylazine.

that I can overdose even if the XTS says there is no xylazine in the heroin, cocaine, or other substance tested.

all responsibility and liability for any injury or death that could occur after ingesting any substance, whether they have been tested or not tested for xylazine.

I confirm this by typing my name below:

Current Progress,

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