Narcan rescue kit order form

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Narcan rescue kit order form - English

Naloxone (Narcan) stops and reverses opioid overdoses. Narcan rescue kits are now available by mail from Lorain County Public Health (LCPH). If you have witnessed someone overdose before, you should probably carry Narcan. Family members, friends, and coworkers of someone who uses drugs should have a Narcan rescue kit on hand, as should anyone in recovery from an opioid problem.

No private information will be shared. A copy of LCPH's privacy statement is available upon request. If you have questions about this form, please contact Natalie at nkarn@loraincountyhealth.com or call 440-322-6367.

Steps:
1) Complete this form
2) Watch the training video at the bottom of this form and answer the training questions
3) Submit this form

LCPH will send you a Narcan rescue kit within 1-3 business days of completing this form. Questions on this form are adapted from Harm Reduction Ohio. Project DAWN, Naloxone distribution program, is funded by a grant from the Ohio Department of Health.

Your age *

14 or under

15-24

25-34

35-44

45-54

55-64

65+

Prefer not to say

Which gender do you most identify with? *

Male

Female

Non-Binary/Gender Fluid

Prefer not to say

Other:

What race(s) and ethnicity do you consider yourself? *

White

Black/African American

Hispanic/Latino

Asian

Native Hawaiian/Pacific Islander

American Indian or Alaska Native

Multi-racial/Multi-ethnic

Prefer not to say

Other:

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