RFA #34347-04726 Universal Postpartum Naloxone Project Application

Applicant Information

1. Legal name of applicant as it appears on its corporate charter: *This question is required.

2. Federal Tax ID Number: *This question is required.

3. Is your organization a registered vendor with the State? *This question is required.

Please enter an 'other' value for this selection.

4. Organization contact information: *This question is required.

Primary Mailing Address:
Phone Number:

5. Primary Contact Person: *This question is required.

Name:
Title:
Email Address:
Phone Number:

6. Secondary Contact Person: *This question is required.

Name:
Title:
Email Address:
Phone Number:

7. If awarded a grant, who will be the authorized signer of the resulting contract? *This question is required.

Name:
Title:
Email Address:
Phone Number:

8. Hospital(s) and address(es) where services will be provided: *This question is required.

9. Average number of deliveries per year for the past 5 years (per hospital): *This question is required.

10. At the time of application, what is the expected number of mothers who will receive a family first-aid kit and naloxone (per hospital)? *This question is required.

11. Anticipated cost per kit ($): *This question is required.

12. Please check ONE of the following as it applies to this application.
*This question is required.

13. Please upload a document with your requested changes.

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13. Please upload your signed Competitive Requirements form here: *This question is required.

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