Fentanyl Test Strip Request Form - MCPH (Ver 1.0 Rev 7/7/2023)

To receive 5 Fentanyl Test Strips (FTS) from Mahoning County Public Health:

1.) Answer the questions and submit this request form.

2.) Fentanyl is an opioid painkiller that can cause severe breathing problems or death in high doses. Fentanyl can be found in a number of street drugs. Naloxone, also called NARCAN®, is a medication that can reverse an overdose from opiates, including fentanyl, and save lives by blocking the effects of opioids on the brain and quickly restoring breathing. You can also request a Narcan Kit from this request form.

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

4.) If picking up, you will receive a phone call or email stating that your request form was received and when your FTS 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 (closed on federal holidays) to pick up your FTS.

Question Title

* 1. Please enter today's date.

Date

Question Title

* 2. I acknowledge and accept.... (check each of the boxes)

all responsibility and liability for possessing the test strips

that a wide variety of substances can be laced with fentanyl. While it is advisable to test substances for fentanyl, there are no well-researched, established recommendations on how to test drugs with test strips.

that there is a possibility that the test strips may not indicate the presence of fentanyl and that they are not guaranteed to detect all forms of fentanyl.

that I can overdose even if the strip says there is no fentanyl in the heroin, cocaine, or other substances tested.

all responsibility and liability for any injury or death that could occur after ingesting any substance, whether they have been tested, or not tested for fentanyl.

I confirm this by typing my name below

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* 3. How would you prefer to receive your Fentanyl Test Strips?

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 to the address listed above (Mahoning County Residents ONLY)

Question Title

* 4. Please list your contact information, so we may mail your FTS or to contact you to let you know that your FTS can be picked up.

Street Address

City

State

Zip Code

Phone number

Email Address

Agency Name, if applicable

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* 5. How did you hear about our FTS distribution 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

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* 6. Would you like to receive a Narcan kit also?

Yes