Naloxone Kit Request Form

Please complete the following questionnaire to request a free Naloxone (Narcan) kit. Only Lucas County residents are eligible to apply.

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1. What Ohio county do you currently live in?

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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 to previous question, 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. Included in each naloxone (Narcan) kit you will receive: 2 doses of 4 mg Narcan Nasal Spray, 1 face shield, pair of sterile gloves, Project DAWN pouch, naloxone education materials (see image below). Please check that you understand and/or if you want to be contacted for more information.   

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8. I am requesting a naloxone (Narcan) kit as...

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10. Do you have health insurance

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11. Intended use of naloxone (Narcan): (check all that apply)

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12. Have you ever...(check all that apply)

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13. If you've overdosed before, how many times?

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14. Is this the first naloxone (Narcan) kit you have ever received?

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15. What happened to your previous naloxone kit? (only answer if you answered NO to above question)

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16. Did the person that the kit was used on survive? (only answer if your naloxone kit was used on someone)

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17. How many times have you witnessed someone overdosing?

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18. How many times have you administered (used) naloxone (Narcan) on someone?

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19. To receive your free Project DAWN naloxone (Narcan) kit, please watch this training video in it's entirety.

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20. To have a Project DAWN naloxone (Narcan) kit sent to you, please provide a Lucas County mailing address and phone number (in the event we need to reach you). Naloxone (Narcan) kits will NOT be available for those outside of Lucas County.

If you have any questions about how to use the kit or need additional counseling you can talk to a TLCHD public health nurse at 419-213-4204 between the hours of 8:30AM and 4:30PM weekdays or visit our office at 635 N. Erie Street, Toledo, OH 43604.

When you administer naloxone, always call 911!

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