Mail Order Naloxone Form Project DAWN Intake Form The Project DAWN, naloxone distribution program, is funded by a grant from the Ohio Department of Health. The below questions are a requirement of the ODH program, therefore, all questions are required to be answered to the best of your ability. OK Question Title * 1. Date of Request Date / Time Date OK Question Title * 2. How old are you? OK Question Title * 3. What sex were you assigned at birth, on your original birth certificate? Male Female Prefer not to say OK Question Title * 4. Do you consider yourself to be transgender or non-binary? Yes No Prefer not to answer OK Question Title * 5. If YES, do you consider yourself to be: Male-to-female Female-to-male Gender nonconforming Prefer not to say OK Question Title * 6. What race(s) and ethnicity do you consider yourself? (check all that apply) White Black or African American Hispanic or Latino Asian or Asian American American Indian or Alaska Native Native Hawaiian or other Pacific Islander Other (please specify) OK Question Title * 7. In which Ohio county do you live? Delaware County Hardin County Knox County Madison County Union County Unknown/Not Available I do not live in Ohio Other Ohio County If other please specify: OK NEXT