Harm Reduction Supply Request Form

The Midland County Department of Public Health offers harm reduction supplies for safer use, at no cost.

Complete and submit this supply request form, and we will gather your requested supplies for pick-up at the Midland County Department of Public Health during business hours:

Midland County Services Building (4 story brown brick building by downtown Midland)
220 West Ellsworth Street
Second Floor, Room 231 (room numbers can be found at the top of the door frame)
Midland, MI 48640

Open Monday-Friday 8am-12pm and 1pm-5pm

Please call us with any questions: 989-832-6380 (option #1)

1. Participant ID- we use a participant ID instead of requiring your full name to promote confidentiality. When you pick up your supplies, we will ask for your participant ID.

ID Format: First letter of first name + 2 digit day of birth + 2 digit month of birth

Example: Jo born on the 15th of March= J1503 *This question is required.

First letter of first name:
2 digit day of birth
2 digit month of birth

2. Use the drop-down menu to identify how many you would like of each item listed.

Note- we will do our best to fill your order as requested based on availability of supplies.

Naloxone Kit (includes 2 doses of naloxone nasal spray, gloves, & rescue breathing shield)
Fentanyl Test Strips
Xylazine Test Strips
Medetomidine Test Strips
Nitazene Test Strips
29g Sharps
31g Sharps
Aluminum Cooker w/ Handle
Sterile Cotton Syringe Filter (pack of 5)
VitC/Ascorbic Acid Packet
Tourniquet
Sterile Water
Stem Kit (4" stem, mouthpiece, pusher, screens, wipe)
Bubble Kit (4" glass bubble pipe, mouthpiece, wipe, lip balm)
Wound Care Kit (Band-Aids, gauze, alcohol swabs, sterile water, bacitracin)
Band-Aid
Gauze
Alcohol Swab
Bacitracin
Lip Balm
Small Sharps Disposal Container (1 quart)
Large Sharps Disposal Container (1 gallon)
Lock Bag W/ Lock
Gun Lock (cable style)
Program Participant ID Card
Take Cover Kit (contains condoms and lubrication)

3. Are there any details you would like to share about your request?

4. Many services are available on a sliding fee scale or may be available at no-cost.

Please note, we will need to gather more personal identifying information than your Participant ID for these services, but all personal information is handled confidentially.

Some services are available by walk-in, but others do need an appointment (see list below for services with walk-in options).

Please check the box next to any services you are interested in. At the end of this form, you will see a separate link to electronically request an appointment, or you are welcome to call us at 989-832-6380 (option 1) to schedule.

5. How did you learn about the Midland County Department of Public Health (MCDPH) harm reduction program? *This question is required.

Friend
Family
MCDPH Facebook
MCDPH Website
Saw "Harm Reduction" stations in the community
Flyer
Other - Write In Please enter an 'other' value for this selection.

6. If you know approximately what day you might pick up your request, please give us a general idea:

7. If you would like us to send a generic text when your request is ready for pickup, please provide your phone number (this is offered as an option for your convenience, but not required).

Harm Reduction Supply Request Form

Harm Reduction Supply Program