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Naloxone Intake Form
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1.
In which Ohio zip code do you live?
(Required.)
I live in Ohio
I do not live in Ohio- Stop here.
Zip Code
2.
If you Live in Ohio Please provide your name, address, and phone number.
3.
Your age
Under 14
15-24
25-34
35-44
45-54
55-64
65+
Prefer not to say
4.
Which gender do you most identify with?
Female
Male
Non-Binary / Gender Fluid
Prefer not to say
Not listed
5.
What race(s) and ethnicity do you consider yourself? Please choose one.
American Indian or Alaska Native
Asian or Asian American
Black or African American
Hispanic or Latino
Middle Eastern or North African
Native Hawaiian or other Pacific Islander
White
Another race
Other
Prefer not to say
Multi-racial / multi-ethnic (check all that apply)
6.
In which Ohio county do you live?
I prefer not to answer
I do not live in Ohio
County
7.
Have you used drugs in the last year? (other than marijuana)
Yes
No
Prefer not to answer
8.
Have you ever overdosed or witnessed an overdose?
Yes
No
Prefer to answer
9.
Is this the first Naloxone (Narcan) kit you have received?
Yes
No
Prefer not to answer
10.
In no, what happened to your previous kit?
My kit was used on me or someone who was overdosing
The medication in my kit expired
Other
Prefer not to say
11.
If the previous kit was used on someone overdosing, did they survive?
Yes
No
Prefer not to answer