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* 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?

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* 2. Today's date?

Date

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* 3. Is this your first time using the machine?

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* 4. Have you utilized any harm reduction services before this machine?

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* 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.

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* 6. Are you a University of Cincinnati student?

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* 7. How do you describe your race/ethnicity?

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* 8. Age

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* 9. Gender identity

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* 10. What is your current zip code?

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* 11. Which of the following items are you interested in obtaining from the machine?

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* 12. Do you need guidance on how to administer Naloxone (Narcan)?

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* 13. What services are you interested in?

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* 14. Do you have a reliable means of transportation?

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* 15. Would you like us to follow up with you?

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* 16. If yes, please provide your preferred method and contact (email or phone) information.

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* 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.

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* 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.

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