Harm Reduction Machine Registration Question Title * 1. To best care for those who use this machine, our organization keeps track of what products and services are being provided from this machine. This helps us determine how effective we are at helping people such as yourself. This information will be safely stored and protected with encrypting software. The only information shared would be related to what products and services are dispensed and the demographics of clients that we reach with this service. No information shared will contain any information that is identifiable to you. You may request to withdraw from this process at any time and if you have any questions, you may reach us at the Clermont County Mental Health and Recovery Board at (513) 732-5400.May we have your permission to continue? Yes No Question Title * 2. Today's date? Date / Time Date Question Title * 3. Is this your first time using the machine? Yes No Question Title * 4. Have you utilized any harm reduction services before this machine? Yes No Question Title * 5. Participant ID: Please create your participant ID by combining the first letter of your first name, and the first three letters of your last name. Question Title * 6. How do you describe your race/ethnicity? White Black or African American Hispanic or Latino Asian or Asian American American Indian or Alaska Native Native Hawaiian or other Pacific Islander Another race Question Title * 7. Age 18-24 25-34 35-44 45-54 55-64 65+ Question Title * 8. Gender identity Male Female Non-binary Transgender Other/Don't know Question Title * 9. What is your current zip code? Question Title * 10. Which of the following items are you interested in obtaining from the machine? Naloxone (Narcan Spray) Drug Disposal Bag First Aid Kit Sharps Container Hygiene Kit Safer Sex Kit Wound Care Kit Fentanyl Test Strips Question Title * 11. Do you need guidance on how to administer Naloxone (Narcan)? Yes No Question Title * 12. What services are you interested in? Adult Mental Health Services Youth Mental Health Services Addiction Services Crisis Services None Question Title * 13. Do you have a reliable means of transportation? Yes No Maybe (partial) Question Title * 14. Would you like us to follow up with you? Yes No Question Title * 15. If yes, please provide your preferred method and contact (email or phone) information. Question Title * 16. Machine Access Code: Please provide the last four digits of your social security number. These four digits will be your code to use at the machine. Question Title * 17. Your access to the machine will take approximately one business day to activate. After this time, you will be able to obtain items using the last four digits of your social security number as provided above. *Please note, the machine display refers to this access code as "Employee ID". By checking the following box, you acknowledge that you take sole responsibility for items obtained from the machine, that you will not share your access code with any other person, and that you understand that an overdose is a life-threatening medical emergency and that 911 will always be called during such an event. I acknowledge the above statement Done