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Please complete the following questionnaire to request a free Naloxone (Narcan™) kit. Patients/family of TCN Behavioral Health, DeCoach Rehabilitation Centre, SafeTrade (syringe service program) participants, and all other OHIO residents/workers are eligible to apply. 

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* 1. What is your affiliation?

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* 2. Date of Request (note: all requests will be filled each Wednesday and Friday. Please allow 7-10 days to fulfill your request) If you have an immediate need for a naloxone kit, please call contact 937-374-5621 or 937-479-8848 to arrange for a pick up at Greene County Public Health

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* 3. How old are you?

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* 4. What gender do you most identify with?

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* 5. What race(s)/ethnicities do you consider yourself to be? (Check all that apply)

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* 6. Select the image below to confirm you see it:

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* 7. Watch the following training video and confirm you have watched it: https://www.youtube.com/watch?v=dBF0ovVWPYc

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* 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. **Kits must be kept at room temperature**

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* 9. In which Ohio ZIP CODE do you live? (Please note if you do not live in Ohio)

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* 10. In which Ohio COUNTY do you live? (Please note if you do not live in Ohio)

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* 11. Is this the first Narcan kit you have received?

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* 12. If NO, then

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* 13. Intended Use for Naloxone (Check All that Apply):

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* 14. Please enter your FULL NAME and MAILING ADDRESS 

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