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* 1. Name:

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* 2. E-mail address:

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* 3. Phone number:

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* 4. Company (if applicable):

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* 5. Name of your proposed idea/activity:

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* 6. Please describe your proposed activity, including examples of where similar activities have been successfully enacted. (500 words or less)

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* 7. How does this activity align with the goals of the State Opioid Response grant program? (20 words or less)

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* 8. If applicable: Please include URL links to reference materials or research articles discussing the evidence behind this activity, and/or popular press articles describing successful implementation of similar activities elsewhere.

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