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Naloxone Distribution Request
The distribution of naloxone for this program is supported by the Department of Health and Human Services and administered by the Maine Naloxone Distribution Initiative (MNDI). MNDI’s state-supported naloxone is available at no charge.
1.
Date of Request
Date / Time
Date
January
February
March
April
May
June
July
August
September
October
November
December
1900
1901
1902
1903
1904
1905
1906
1907
1908
1909
1910
1911
1912
1913
1914
1915
1916
Su
Sunday
Mo
Monday
Tu
Tuesday
We
Wednesday
Th
Thursday
Fr
Friday
Sa
Saturday
01
02
03
04
05
06
07
08
09
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
2.
First Name
3.
Last Name
4.
Title
5.
Agency
6.
AgencyType
Commercial Business - e.g., restaurants, construction companies, and retail business establishments
Community organizations that are not harm reduction organizations - e.g., veteran organizations, libraries
Criminal justice - e.g., courts, jails, prisons, probation, and parole
Education - e.g., schools, colleges, and universities
Faith-based - Faith-based organizations
First responders - e.g., police departments, fire departments, and emergency medical services
Health Center - e.g., community health centers or federally qualified health centers
Hospitals and emergency departments
Mental health treatment facilities - e.g., certified community behavioral health clinics and other community mental health centers
Municipal Health - e.g., local health departments or county health departments
Other types of entities
7.
If Other Types of Entities:
Pharmacy
Harm Reduction Organizations - e.g., syringe services programs
Recovery - e.g., recovery community organizations, recovery housing, and sober living homes
Shelters or agencies that provide services to people experiencing homelessness
Substance use disorder (SUD) treatment facilities - e.g., SUD outpatient, opioid treatment programs, and residential treatment facilities
Tribal Business - Tribally run businesses (e.g., casinos, hotels, and stores)
Tribal government entities - e.g., education, human services, or public works department
Other (please specify)
8.
Physical Address 1
9.
Physical Address 2
10.
City/State/Zip
11.
County
12.
Telephone
13.
Email
14.
Number of naloxone nasal spray kits (2 doses per kit) your agency/organization anticipates distributing within the next six months?
15.
Number of intramuscular naloxone kits (2 doses per kit) your agency/organization anticipates distributing within the next six months
16.
Does your organization already purchase or have access to naloxone?
Yes
No
17.
Why is your organization requesting state-supplied naloxone?t
18.
If your organization is already distributing naloxone, whose standing order are you operating under?
Thank you for submitting! A member of the MNDI team will be in contact within 3-5 business days. If you have any questions regarding naloxone in Maine, please visit GetMaineNaloxone.org or reach out to Naloxone.ME@maine.gov
