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Harm Reduction Machine Registration
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
2.
Today's date?
Date / Time
Date
January
February
March
April
May
June
July
August
September
October
November
December
1900
1901
1902
1903
1904
1905
1906
1907
1908
1909
1910
1911
1912
1913
1914
1915
1916
Su
Sunday
Mo
Monday
Tu
Tuesday
We
Wednesday
Th
Thursday
Fr
Friday
Sa
Saturday
01
02
03
04
05
06
07
08
09
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
3.
Is this your first time using the machine?
Yes
No
4.
Have you utilized any harm reduction services before this machine?
Yes
No
*
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.
(Required.)
6.
Are you a University of Cincinnati student?
Yes
No
7.
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
8.
Age
18-24
25-34
35-44
45-54
55-64
65+
9.
Gender identity
Male
Female
Non-binary
Transgender
Other/Don't know
10.
What is your current zip code?
11.
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
12.
Do you need guidance on how to administer Naloxone (Narcan)?
Yes
No
13.
What services are you interested in?
Adult Mental Health Services
Youth Mental Health Services
Addiction Services
Crisis Services
None
14.
Do you have a reliable means of transportation?
Yes
No
Maybe (partial)
15.
Would you like us to follow up with you?
Yes
No
16.
If yes, please provide your preferred method and contact (email or phone) information.
*
17.
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.
(Required.)
18.
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