CCA Coalitions/Members Narcan & Deterra Request

NOTE- Survey is asking for number of units of Narcan, each person usually gets 1 unit (1 box of 2 single dose nasal spray devices) of Narcan. Please state how many individual units you would like.

**** Please submit request at least 1 MONTH prior to the date needed.

Question Title

* 1. Please provide your information below:

Organization Name

County

First Name

Last Name

Position

Tel.

Question Title

* 2. County where the Narcan/Deterra will be distributed:

Question Title

* 3. Number of Narcan units needed?

NOTE- Survey is asking for number of units of Narcan, each person usually gets 1 unit (1 box of 2 single dose nasal spray devices) of Narcan. Please state how many individual units you would like.

CCA Coalitions/Members Narcan & Deterra Request

Question Title

* 1. Please provide your information below:

Question Title

* 2. County where the Narcan/Deterra will be distributed:

Question Title

* 3. Number of Narcan units needed?

NOTE- Survey is asking for number of units of Narcan, each person usually gets 1 unit (1 box of 2 single dose nasal spray devices) of Narcan. Please state how many individual units you would like.

Question Title

* 4. Number of Deterra bags needed?

Question Title

* 5. Please provide a brief description of why Narcan/Deterra request is being submitted.

Question Title

* 6. Date of event/strategy the Narcan/Deterra is needed:

CCA Coalitions/Members Narcan & Deterra Request

Question Title

* 1. Please provide your information below:

Question Title

* 2. County where the Narcan/Deterra will be distributed:

Question Title

* 3. Number of Narcan units needed?NOTE- Survey is asking for number of units of Narcan, each person usually gets 1 unit (1 box of 2 single dose nasal spray devices) of Narcan. Please state how many individual units you would like.

Question Title

* 4. Number of Deterra bags needed?

Question Title

* 5. Please provide a brief description of why Narcan/Deterra request is being submitted.

Question Title

* 6. Date of event/strategy the Narcan/Deterra is needed:

* 3. Number of Narcan units needed?

NOTE- Survey is asking for number of units of Narcan, each person usually gets 1 unit (1 box of 2 single dose nasal spray devices) of Narcan. Please state how many individual units you would like.