Naloxone Request Form for Community Partners

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This form is for community partners to submit naloxone requests.

To be eligible to request naloxone, you must:

Be a Rhode Island-based non-profit organization, municipality or community-based organization,
Have been trained in overdose response and naloxone administration, and
Agree to fulfill data entry requirements for naloxone distribution.

Please note: Naloxone is a medicine that must be properly stored; follow all directions for proper usage prior to using. Naloxone cannot be resold.

Requestor Contact Person Name

* must provide value

Requestor Contact Person Email Address

* must provide value

Primary Contact Person Name

* must provide value

Primary Contact Person Email Address

* must provide value

Primary Contact Person Phone Number

* must provide value

Organization/ Agency Name

Organization/Agency Name

* must provide value

Other, please specify

What type of naloxone are you requesting today?

* must provide value

Intranasal (Narcan)

Intramuscular

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Is this your first request for naloxone from the State of Rhode Island (URI/BHDDH/PONI/RIDOH/EMS)?

* must provide value

Yes

Don't know

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From which state agency did you most recently receive naloxone?

* must provide value

BHDDH

RI EMS

RIDOH

URI

What was the most recent date your organization received naloxone?

M-D-Y

How many naloxone kits did your organization receive?

* must provide value

How did your organization obtain naloxone prior to this request?

* must provide value

Direct Purchase

Pharmacy

Recovery Community Center

Mobile Outreach Team

BHDDH

HEZ: Health Equity Zones

PONI: Preventing Overdose and Naloxone Intervention

RI EMS

Rhode Island Disaster Medical Assistance Team (RIDMAT)/ Medical Reserve Corp

SAMHSA

None of the above. This is my first time requesting any type of naloxone.

Other (please specify)

If other, please specify

* must provide value

Number of intranasal naloxone kits requested

* must provide value

Is naloxone delivery required?

How would you like to receive your naloxone order?

Delivery Address

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Date Naloxone Needed

M-D-Y

Number of intramuscular naloxone kits requested

* must provide value

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What is the primary targeted or intended population(s) for the distribution of the requested naloxone kits? Please select the one population that is most representative of your intended distribution model.

* must provide value

High-Risk Population - Mobile Outreach

High-Risk Population - Substance Use Treatment Center

High-Risk Population - Other Points of Care

Fire/EMS Program

Law Enforcement Program

Leave-Behind Program

Community Training

Mail Order Naloxone

Other (please specify)

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If other, please specify

* must provide value

What is/are the intended primary city/town(s) of distribution?

* must provide value

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Pick-Up Contact Person Name

* must provide value

Pick-Up Contact Person Email Address

* must provide value

Have you received naloxone training?

* must provide value

Yes

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What was the date of your most recent training?

* must provide value

M-D-Y

Have you connected with a qualified naloxone trainer?

* must provide value

Yes

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Data Entry Contact Person Name

* must provide value

Data Entry Contact Person Email Address

* must provide value

Which Agency Will Follow Up With This Request?

BHDDH/DMAT

PONI

EMS/CARA

URI

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Was the organization/ agency approved for naloxone?

Yes, approved

Yes, approved with a different amount of naloxone

No, not approved

On hold

Other (please specify)

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If other, please specify

Date of email response to organization/agency

M-D-Y

How many naloxone kits was the organization/agency approved to distribute?

Date of email follow up to organization/agency

M-D-Y

How many additional kits was the organization/agency approved to distribute?

Date of second follow up

M-D-Y

How many additional kits were approved (2nd Follow Up)?

Please describe why

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Notes

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Pick-Up Date

Assigned Naloxone Kits

Follow Up Pick Up Date

Follow Up Assigned Naloxone Kits

Second Follow Up Pick Up Date

M-D-Y

Second Follow Up Assigned Naloxone Kits

Request Status

Open

Closed

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Was the organization/agency naloxone request filled?

Yes, request complete

Yes, requested complete with a different amount of naloxone

No, not complete

On hold

Other (please specify)

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Assigned Naloxone Kits

Number of kits filled

Notes

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Was the organization/agency naloxone request filled?

Yes, request complete

Yes, request complete with a different amount of naloxone

No, not complete

On hold

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Number of kits filled

Assigned Naloxone Kits

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Pick Up/ Drop Off Date

M-D-Y

Notes

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Was the organization/ agency approved for naloxone?

Yes, approved

Yes, approved with a different amount of naloxone

No, not approved

On hold

Other (please specify)

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Number of kits filled

Pick Up/ Drop Off Date

M-D-Y

Notes

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