Harm Reduction Tool Request Form for Lay Rescuers

Note about Narcan Distribution Form

Norfolk Prevention Coalition only provides Narcan to Lay Rescuers in Norfolk, Portsmouth, Chesapeake, Virginia Beach, Suffolk, and Isle of Wight.

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* 1. Personal Information:

Name:

Address:

Phone Number:

Email:

Date of Birth:

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* 2. What Harm Reduction tools do you need? (Please check all that apply)

Promotional Flyers

Narcan

Drug Deactivation Kit

Pill Bottle Timer Cap

Medication Lock Box

Other (please specify)

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* 3. Training and Certification: Have you received training on the proper use of Narcan (naloxone)?

If yes, please provide details of the training (date, location, trainer, etc.).

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* 4. Distribution Details: Reason for requesting Narcan

Personal use

Family member or friend at risk

Other (please specify)

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* 5. Who referred you to this Narcan distribution program?

DeAndre Fulton

ShQuita Boone

Archie Boone Jr.

Social Media Post

Friend or Family Member

Other (please specify)

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* 6. Understanding and Agreement:I understand that Narcan is to be used in emergency situations to reverse opioid overdoses and should only be administered by trained individuals. I agree to use Narcan responsibly and to seek medical help immediately after administration. I also understand that the distribution of Narcan is subject to local laws and regulations.

Typed Full Name to be Adopted as Your Signature:

Date:

Harm Reduction Tool Request Form for Lay Rescuers

Note about Narcan Distribution Form

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* 1. Personal Information:

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* 2. What Harm Reduction tools do you need? (Please check all that apply)

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* 3. Training and Certification: Have you received training on the proper use of Narcan (naloxone)?

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* 4. Distribution Details: Reason for requesting Narcan

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* 5. Who referred you to this Narcan distribution program?

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