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. 

All organizations receiving naloxone through this program will be required to provide brief monthly reports of naloxone distribution, administration, overdose encounters and overdose reversals. If you have previously ordered naloxone and have not completed a monthly report please do so now using this link: https://forms.office.com/pages/responsepage.aspx?id=-M4x_Ne3_UiwDJKd6I52bQEQkDKcJgFNlhUy4ALU6zBUOU41VklXTDJDQVk3ODk4OTFUTExHME03NS4u&route=shorturl


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
2. Shipping Address (Include City) - NO PO Box
3. Organization Contact Name
4. Organization Contact Phone
5. Organization Contact Email
6. Organization Size
7. County
8. Organization's Estimated Service Population
9. Organization Type
9. Organization Type
 
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?
Training Information
11. Has your organization been trained in naloxone administration?
11. Has your organization been trained in naloxone administration?
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?
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.
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.
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).
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.
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.