Only complete this survey if you want to sign up to receive real-time overdose alert notifications.

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* 1. Who are you? (first and last name please)

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* 2. Where do you work?

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* 3. How do you want to receive your overdose alerts? (select all that apply)

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* 4. If you choose to receive your alert via voice message, please provide a telephone number here.

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* 5. If you choose to receive your alert via text message, please provide a CELL phone number here.

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* 6. If you choose to receive your alert via email, please provide an email address here.

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* 7. Are you a member of the Roots of Prevention or Regional Recovery Consortium?

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* 8. Do you identify as any of the following? (check all that apply)

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* 9. Do you live and or work in any of the following counties? (check all that apply)

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