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. Question Title * 1. Date of Request Date / Time Date Question Title * 2. First Name Question Title * 3. Last Name Question Title * 4. Title Question Title * 5. Agency Question Title * 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 Question Title * 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) Question Title * 8. Physical Address 1 Question Title * 9. Physical Address 2 Question Title * 10. City/State/Zip Question Title * 11. County Question Title * 12. Telephone Question Title * 13. Email Question Title * 14. Number of naloxone nasal spray kits (2 doses per kit) your agency/organization anticipates distributing within the next six months? Question Title * 15. Number of intramuscular naloxone kits (2 doses per kit) your agency/organization anticipates distributing within the next six months Question Title * 16. Does your organization already purchase or have access to naloxone? Yes No Question Title * 17. Why is your organization requesting state-supplied naloxone?t Question Title * 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 Done
