Project DAWN (Narcan Kit) Order Form

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Naloxone (Narcan) stops and reverses opioid overdoses. Narcan rescue kits are now available by mail from Portage County Health District (PCHD). 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 PCHD's privacy statement is available upon request. If you have questions about this form, please contact Kylee at kmccracken@portagehealth.net or call 330-296-9919, ext. 129.

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

PCHD 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.

This program is only for Ohio residents.

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:

Please type the address you want the Project DAWN Kit delivered to. Example: 999 East Main Street *

City *

State *

Ohio

Zip Code *

What Ohio County do you live? *

Portage County

Prefer not to say

Other:

What name would you like the package addressed to? *

Have you used drugs in the last year (other than marijuana)? *

Yes

Prefer not to say

Have you overdosed or witnessed an overdose? *

Yes

Prefer not to say

Is this the first Project DAWN Kit you have received? *

Yes

Prefer not to say

If you received a Project DAWN Kit before, what happened to your previous Kit? *

My kit was used on another person who was overdosing.

My kit was used on me.

The medication in my kit expired.

Other:

How did you hear about the Project DAWN program at PCHD? *

Family/Friend/Coworker

Treatment Center

Social Media (Facebook, Twitter)

Ohio Department of Health

Other:

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