DHW Naloxone Request Form 2.0
The Idaho Department of Health and Welfare (DHW) offers free naloxone to organizations throughout Idaho. To request naloxone for your organization, please complete and submit this form. Free naloxone is contingent upon continued federal and state funding and available supply.
Orders placed through September 2025 may be partially fulfilled due to stock limitations. The complete fulfillment of Naloxone orders will resume in October 2025.
We encourage organizations to receive training on naloxone administration and to know the signs of an opioid overdose. To learn more about naloxone and signs of an overdose, please visit:
Overdose Response | Idaho Department of Health and Welfare
.
Organization Information
1. Organization Name
1. Organization Name
2. Shipping Address (Include City) - NO PO Box
2. Shipping Address (Include City) - NO PO Box
3. Organization Contact Name
3. Organization Contact Name
4. Organization Contact Phone
4. Organization Contact Phone
5. Organization Contact Email
5. Organization Contact Email
6. Organization Size
6. Organization Size
7. County
7. County
8. Organization's Estimated Service Population
8. Organization's Estimated Service Population
9. Organization Type
9. Organization Type
Ambulance
Corrections
Crisis Center
Emergency Department
Fire Department
Shelter
Law Enforcement
K-12 School
University/College
Public Health District
Recovery Center
Community-Based Service Organization (formerly Safer Syringe Program)
SUD Treatment Center
Community-Based Business, Group, Individual
Pharmacy
State or Local Government
Other
Other
Naloxone Procedure
10. Organization has a naloxone storage, handling, and administration procedure or policy in effect?
10. Organization has a naloxone storage, handling, and administration procedure or policy in effect?
Yes
No
Training Information
11. Has your organization been trained in naloxone administration?
11. Has your organization been trained in naloxone administration?
Yes
No
12. Number of organization staff trained.
12. Number of organization staff trained.
13. Would you like to be contacted to schedule a naloxone training for your organization?
13. Would you like to be contacted to schedule a naloxone training for your organization?
Yes
No
Naloxone and Naloxone Accessories Requested
14. Please select the type and quantity of naloxone you would like to request.
14. Please select the type and quantity of naloxone you would like to request.
Naloxone (Narcan) 4mg Dose Nasal Spray 2-Pack
Demo Naloxone (Narcan) Nasal Spray **Training Only**
Total
15. Please select the type and quantity of naloxone accessories you would like to request.
15. Please select the type and quantity of naloxone accessories you would like to request.
Fentanyl Test Strip with Micro Scoop
Total
Naloxone Distribution
16. Tell us how you plan to use DHW provided naloxone (select all that apply).
16. Tell us how you plan to use DHW provided naloxone (select all that apply).
Our staff plans to administer naloxone directly to a community member we suspect has overdosed.
Our staff plans to administer naloxone to other staff members.
Our staff plans to use naloxone for opioid overdose response education and training.
Our staff plans to redistribute naloxone to individuals at risk of an opioid overdose.
Our staff plans to use naloxone as part of a naloxone leave-behind program.
17. Please list the person in your organization responsible for reporting doses distributed, administered, and outcomes.
17. Please list the person in your organization responsible for reporting doses distributed, administered, and outcomes.
Name
Email
By submitting this request form, I acknowledge that organizations receiving naloxone through this program will be required to provide brief monthly reports of naloxone distribution, administration, overdose encounters and reversals.
By submitting this request form, I acknowledge that all naloxone products and accessories received from this request are not allowed for resale.
