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Public Health

Naloxone Kit Request Form

Naloxone Kit Request Form

If you would like to request naloxone kits or other assistance, please fill out this form and hit the submit button below.

Organization Information

Are you a:

Contact Information

Name and title of the person(s) who will be responsible for ordering, receiving, and distributing naloxone for your
organization.

Additional Organization Information

What type of organization does your agency most closely identify as? Check as many boxes as appropriate.
What population(s) does your agency serve? Check as many boxes as appropriate.

Naloxone Kits and Harm Reduction Supplies

Does your organization need any of the following supplies?

Number of kits you would like to order:

Bystander Kit (2 doses of naloxone and instructions for administration)

For those likely to witness and respond to an overdose. Includes 2 doses of Narcan and instructions for use

At-risk of Overdose Kit: (2 doses of naloxone, instructions for administration, resources)

ENGLISH/SPANISH VERSION
To distribute to those likely to experience an overdose. Includes 2 doses of Narcan and resources.
Single use

Includes decals.
Includes posters.

Other Supplies

Each kit includes: (8) Alcohol prep pads / (8) Benzalkonium Chloride towelettes / (5) Bandaids / (2) 4x4 Woven gauze sponges / (2) 2x2 Woven gauze sponges / (2) Petrolatum skin protectant packets / (2) Bacitracin first aid antibiotic ointment packets / (1) Hot compress / (1) ABD sterile pad / (1) Medical tape roll / (1) Cohesive Bandage / (1) Pair of large nitrile gloves & (1) Wound and abscess care flyer
1 quart sharps containers will safely hold approximately 50 used syringes; Plastic material with a hinged lid to provide temporary closure when not in use. For permanent closure the lid will snap for final disposal. The empty containers can be nested to save storage space.
Each pouch will deactivate and dispose of up to 15 pills OR 2oz/60ml, OR 2 patches; Simple three-step process can rid any home of dangerous, leftover drugs in less than three minutes

Training and Technical Assistance

Does your organization need assistance with any of the following:
Please indicate from which location you will pick up your kit(s):
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