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Project DAWN Naloxone Intake Form v3.5 (English)

Demographics

Please complete the following questionnaire to request a free naloxone kit.  Based on your eligibility, a naloxone kit will be mailed within 72 hours of approval of the request.  A confirmation email will be sent to notify you of your eligibility.
1. Age *This question is required.
2. Which gender do you most identify with?
3. Which race(s) and ethnicity do you consider yourself? (Select all that apply.)
This question requires a valid number format.
5. In which Ohio county do you live? *This question is required.
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