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: Health Clinic Treatment Provider County Agency Business Community Based Organization (CBO) Other… Enter other… Org Contact Organization Name Email Phone Address City State - Select -AlabamaAlaskaAmerican SamoaArizonaArkansasArmed Forces (Canada, Europe, Africa, or Middle East)Armed Forces AmericasArmed Forces PacificCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFederated States of MicronesiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarshall IslandsMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPalauPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyoming ZIP # of staff/volunteers? Contact Information Name and title of the person(s) who will be responsible for ordering, receiving, and distributing naloxone for your organization. Contact Info Name Title Email Phone Additional Organization Information What type of organization does your agency most closely identify as? Check as many boxes as appropriate. Non-profit Jail Re-entry Program Diversion program (e.g., drug court) Drug/opioid treatment program Drop-in program/day shelter Health clinic (e.g., federally qualified health center, rural health center, community health clinic) Syringe service program Other (please describe) Enter other… What population(s) does your agency serve? Check as many boxes as appropriate. Individuals with substance use disorders People experiencing mental health issues People who are houseless Youth LGBTQIA+ Immigrants and refugees Other (please describe) Enter other… 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, fentanyl test strips, resources) ENGLISH VERSION To distribute to those likely to experience an overdose. Includes 2 doses of Narcan, fentanyl test strips, and resources. At-risk of Overdose Kit: (2 doses of naloxone, instructions for administration, fentanyl test strips, resources) SPANISH VERSON To distribute to those likely to experience an overdose. Includes 2 doses of Narcan, fentanyl test strips, and resources. Naloxone Window Decals Includes decals. Naloxone Posters Includes posters. Training and Technical Assistance Does your organization need assistance with any of the following: Naloxone training for your employees Written naloxone policy or procedures for your organization Other (please describe) Enter other… Pick-up Location Please indicate from which location you will pick up your kit(s): Clackamas County Public Services Building(Red Soils Campus)2051 Kaen Rd, Suite #367Oregon City, OR 97045 CAPTCHA This question is for testing whether or not you are a human visitor and to prevent automated spam submissions. Submit