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

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* 2. How old are you?

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

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* 4. Do you consider yourself to be transgender or non-binary?

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* 5. If YES, do you consider yourself to be:

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

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* 7. In which Ohio county do you live?

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