Project Dawn - Mahoning County Public Health (Ver 3.5
Rev 3/1/2023)

Project DAWN Narcan Intake Form

To receive a Project DAWN Kit,

1.) You must have participated in a Project DAWN training or have watched the Project DAWN training video (a link to the video in contained in the intake form).

2.) Answer the questions and submit this Project DAWN Narcan Intake Form.

3. ) Kits can now be mailed to residents of Mahoning County only (indicated by mailing address). You will indicate later in this Intake Form to request to have your kit mailed or you may also pick up your kit at our office.

4.) If picking up your kit, you will receive a phone call or email stating that your intake form was received and when your kits will be ready for you. Then you can go to the Nursing Division at Mahoning County Public Health located at 50 Westchester Drive, Austintown, OH 44515 between the hours of 8 am to 4:30 pm, Monday through Friday to pick up your kit.

Question Title

* What is your age (in years)?

14 and under

15-24

25-34

35-44

45-54

55-64

65 or older

Question Title

* Which gender do you most identify with?

Male

Female

Non-binary/Gender Fluid

Prefer not to say

Other/Not Listed

Question Title

* What race(s) and ethnicity do you consider yourself? (check all that apply)

White

Black/African American

Hispanic/Latino

Asian

Native Hawaiian/Pacific Islander

American Indian or Alaska Native

Other

Prefer not to say

Question Title

* In which Ohio county do you live?

Mahoning County

I do not live in Ohio

Prefer not to say

If you do not live in Mahoning County, please list the name of the Ohio County that you do live in.

Question Title

* Have you used drugs in the last year (other than marijuana)?

Yes

Prefer not to say

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* Have you ever overdosed or witnessed an overdose?

Yes

Prefer not to say

Question Title

* Is this the first Narcan kit you have received?

Yes

Prefer not to say

Question Title

* If this is not your first kit, what happened to your previous kit?

My kit was used on me or another person who was overdosing, and I/they survived

My kit was used on another person who was overdosing, and they did not survive

The medication in my kit expired

Prefer not to say

Other (please specify)

Question Title

* I have watched the Project DAWN training video and understand the following: (check all that apply). Video can be found here.

Risk Factors: Using opioids, having a previous overdose, lowered tolerance, mixing drugs, and other health conditions such as asthma, liver or kidney disease, heart disease or HIV/AIDS.

Signs of an overdose: Unresponsive; slow, shallow, or no breathing, choking, snoring, or gurgling sounds; blue, grey, or ashen lips and fingernails; pale or clammy face; slow or absent pulse; vomiting; or seizures.

Calling 9-1-1

Rescue Breathing (currently not recommended if it is a stranger)

Preparing the Narcan: Peel, Place, and Press

Administering Narcan with repeat administration in 2-5 minutes

Follow-up: placing in recovery position and staying with person overdosing

If the kit is used or expired, you can get a refill by contacting Mahoning County Public Health

Question Title

* I, the Project DAWN participant, understand.... (check each of the boxes)

that if the Narcan is used for an overdose, I agree to report the information to Mahoning County Public Health

that I have watched the training video or participated in a training necessary to receive a kit.

the extreme importance or calling 911 in the event of an overdose and use of Narcan.

I confirm this by typing my name below

Question Title

* What is your name?

First Name

Last Name

Question Title

* Please list your contact information, so we may notify you to receive your kit and to let you know when your kit expires?

Street Address

City

State

Zip Code

Phone number

Email Address

Agency Name, if applicable

Question Title

* How would you prefer to receive your Project DAWN kit?

I will PICK UP at Mahoning County Public Health, 50 Westchester Drive, Austintown, 44515 between 8 AM and 4:30 PM Monday through Friday.

Mail my kit to the address listed above (Mahoning County Residents ONLY)

Question Title

* How would you prefer to be contacted?

Phone call/voice message

Question Title

* How did you hear about our Project DAWN program?

Social Media Post

Flyer and/or Brochure in the community

Mental Health and Recovery Board

Work

Friend/Family member recommended it

Treatment Center, Recovery House, or Support Group

Community agency or community event

Quick Response Team

Law enforcement agency or jail

Hospital or Emergency Department

Mahoning County Public Health website or other website

Project Dawn - Mahoning County Public Health (Ver 3.5 Rev 3/1/2023)

Project DAWN Narcan Intake Form

Question Title

* What is your age (in years)?

Question Title

* Which gender do you most identify with?

Question Title

* What race(s) and ethnicity do you consider yourself? (check all that apply)

Question Title

* In which Ohio county do you live?

Question Title

* Have you used drugs in the last year (other than marijuana)?

Question Title

* Have you ever overdosed or witnessed an overdose?

Question Title

* Is this the first Narcan kit you have received?

Question Title

* If this is not your first kit, what happened to your previous kit?

Question Title

* I have watched the Project DAWN training video and understand the following: (check all that apply). Video can be found here.

Question Title

* I, the Project DAWN participant, understand.... (check each of the boxes)

Question Title

* What is your name?

Question Title

* Please list your contact information, so we may notify you to receive your kit and to let you know when your kit expires?

Question Title

* How would you prefer to receive your Project DAWN kit?

Question Title

* How would you prefer to be contacted?

Question Title

* How did you hear about our Project DAWN program?

Project Dawn - Mahoning County Public Health (Ver 3.5
Rev 3/1/2023)