Note: The Department is  in the preliminary stages of identifying and documenting the need for additional Naloxone within the State of Maine.  Your completion of this survey will help us establish an efficient distribution system. Our intention is to supplement, not supplant, existing inventories of Naloxone statewide. 

Question Title

* Date of Request

Date / Time

Question Title

* FNAME

Question Title

* LNAME

Question Title

* TITLE

Question Title

* PHYSICAL ADDRESS (If you only use one address, please put NA, None, etc. in Address 2)

Question Title

* CITY/TOWN

Question Title

* STATE

Question Title

* ZIP CODE

Question Title

* TELEPHONE

Question Title

* EMAIL

Question Title

* Number of Dual-Kit, Intra-Nasal Naloxone your organization can reasonably distribute/utilize within the next six months:

Question Title

* Number of Intra-Muscular Naloxone doses your organization can reasonably distribute/utilize within the next six months:

Question Title

* Does your organization already have a source (Foundation, Distributor, Vendor) to purchase Naloxone?

Question Title

* Is your organization already distributing/utilizing Naloxone?

Question Title

* Whose Standing Order are you operating under? (If "Yes" was chosen from above)

Question Title

* Will your organization need training or technical assistance?

You will be brought back to SAMHS Forms page once you submit your finished survey.

T