TLCHD Overdose Prevention Program Training Request Form

Naloxone Training Request Form

Trainings take place on a first-come, first-served basis, with priority distribution to agencies and individual participants with stated risk factors.

Participants receiving a naloxone kit at the training will be asked to complete a Project DAWN data collection form consisting of basic demographics. No personal information is collected during trainings.

1. Name of entity requesting a training:

2. Brief description of entity requesting a training:

3. Agency zip code:

4. Contact person name:

5. Contact person email: This question requires a valid email address.

6. Contact person phone number:

7. Estimated number of attendees:

8. In order to best meet the expectations of your entity, please choose education topics based on the following topics (choose all that apply):

Naloxone training and distribution
A brief overview of the history of the opioid epidemic
Current Lucas County trends and statistics
Stigma reduction education
Overview of TLCHD Overdose Prevention and Harm Reduction programs
Other - Write In (Required) Please enter an 'other' value for this selection. * This question is required.

9. Use this box if there is anything else you'd like us to know about the training: