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Project DAWN Naloxone (Narcan ™) Kit Request Form

Please complete the following questions to request a free Naloxone (Narcan™) kit. Any OHIO residents/workers is eligible. 

***The demographic questions are optional to help us determine the outcomes and impact of our program. You will NOT be denied supplies if you don't respond, however, this data is what helps our program remain free to Ohio residents.
1.What is your affiliation/ confirm you are an OHIO resident. (Please note if you do not live in Ohio we are not able to send you naloxone. View out-of-state naloxone resources HERE)(Required.)
2.Have you requested naloxone or fentanyl test strips from us before? (multiple requests are allowed)(Required.)
3.How did you learn about our mail order program?(Required.)
4.What is your current age?(Required.)
5.What gender do you most identify with?(Required.)
6.What race(s)/ethnicities do you consider yourself to be? (Check all that apply)(Required.)
7.Watch the following Narcan training video and confirm you have watched it: https://youtu.be/GtYl2y3iEgw(Required.)
8.Items included in kit: 2 doses 4mg Narcan Nasal Spray, 1 Face Shield, 2 Sterile Gloves, 1 Project DAWN informational booklet, 1 Project DAWN carrying bag. (Required.)
9.In which Ohio ZIP CODE do you live?(Required.)
10.In which Ohio COUNTY do you live?(Required.)
11.Have you used drugs in the last year (other than marijuana):(Required.)
12.Have you ever overdosed or witnessed an overdose?(Required.)
13.Is this the first Narcan kit you have received?(Required.)
14.If NO, what happened to your previous kit?
15.Mailing Address(Required.)
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