Alliance of Coalitions for Healthy Communities

Please complete the form. If you have any questions, contact the office at (248) 221-7101 or email Tracy Chirikas at tchirikas@achcmi.org Upon completion and confirmation from the Alliance that information is correct, a refill will be mailed to you directly. Refills will only be mailed to residents in the United States.

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* 1. Mandatory Information Needed

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* 2. Date you completed training?

Date

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* 3. Kit Number

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* 4. Did the kit expire?

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* 5. Did they use the kit?

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* 6. If yes: Was the life saved?

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* 7. How many doses of Naloxone were used?

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* 8. Was the individual transported by EMS?

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