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. 

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1. Date of Request (Required.)

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2. How old are you? (Required.)

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3. What sex were you assigned at birth, on your original birth certificate?

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4. What race(s) and ethnicity do you consider yourself? (check all that apply) (Required.)

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5. If Multi-racial/multi-ethnic (check all that apply below)

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6. In which Ohio county do you live? (Required.)

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