Coalition/Organization Information

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* 1. Coalition/Organization Name:

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* 2. Coalition/Organization Annual Budget:

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* 3. What communities or populations does your coalition serve?
(Check all that apply)

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* 4. Your coalition/organization addresses the following:
(Check all that apply)

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* 5. Your coalition/organization funding:
(Check all that apply)

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* 6. Your coalition/organization staff are best described as: 
(Check all that apply)

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* 7. Is there currently a Community Overdose Prevention Program in your service area? (i.e. Project Dawn, Naloxone Or Narcan Distribution/Training Sites)

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* 8. If applicable, please indicate the Fiscal Agent supporting your coalition with staff or resources.

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* 9. Which of the 12 Sectors are actively engaged with your Coalition/Organization?
(Check all that apply)

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* 10. Is A Certified Prevention Specialist on your staff or a part of your coalition?

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* 11. If you answered "Yes" to the previous question, what level of certification is this Prevention Specialist(s)?
(Check all that apply)

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* 12. What trainings or special certifications have you or your coalition completed?

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* 13. What does your organization/coalition need assistance with?
(Check all that apply)

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