Mail Order Naloxone Form

Project DAWN Intake Form

The Project DAWN, naloxone distribution program, is funded by a grant from the Ohio Department of Health. The below questions are a requirement of the ODH program, therefore, all questions are required to be answered to the best of your ability.

Question Title

* 1. Date of Request

Date / Time

Date

Question Title

* 2. How old are you?

Question Title

* 3. What sex were you assigned at birth, on your original birth certificate?

Male

Female

Prefer not to say

Question Title

* 4. Do you consider yourself to be transgender or non-binary?

Yes

Prefer not to answer

Question Title

* 5. If YES, do you consider yourself to be:

Male-to-female

Female-to-male

Gender nonconforming

Prefer not to say

Question Title

* 6. What race(s) and ethnicity do you consider yourself? (check all that apply)

White

Black or African American

Hispanic or Latino

Asian or Asian American

American Indian or Alaska Native

Native Hawaiian or other Pacific Islander

Other (please specify)

Question Title

* 7. In which Ohio county do you live?

Delaware County

Hardin County

Knox County

Madison County

Union County

Unknown/Not Available

I do not live in Ohio

Other Ohio County

If other please specify: