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Naloxone Request Form 2026

Vermont Naloxone / Narcan & Harm Reduction Supplies Request Form

If you are not yet an established site and are looking to become a new distribution site, please fill out the New Site Screening Form

Please allow up to 3 weeks to receive the shipment. If you have any questions or concerns or are in urgent need of supplies, please email naloxone@vermont.gov or include your question in the additional requests at the bottom of the form.

1. Organization Name (Please do not use acronyms) *This question is required.

2. Point of Contact

First Name *This question is required.

Last Name *This question is required.

Job Title

Mailing Street Address *This question is required.

Apt/Suite/Office

City *This question is required.

State *This question is required.

Zip *This question is required.

Email Address *This question is required. This question requires a valid email address.

Phone Number *This question is required.

County *This question is required.

Preferred Shipping method:

3. Please Indicate Your Organization Type (Choose One) *This question is required.

Please enter an 'other' value for this selection. * This question is required.

4. How does your organization use these kits/resources? [Check all that apply] *This question is required.

to use as an emergency medication in a workplace
Community distribution to members of the public
Emergency Responder (fire / EMS / LE)
Other - Write In (Required) Please enter an 'other' value for this selection. * This question is required.