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. How much time can you allot for this training?

9. 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 (20 minutes)
A brief overview of the history of the opioid epidemic (10 minutes)
Current Lucas County trends and statistics (15 minutes)
Stigma reduction education (10 minutes)
Overview of TLCHD Overdose Prevention and Harm Reduction programs (10 minues)
Other - Write In (Required) Please enter an 'other' value for this selection. * This question is required.

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