Lay Distributor Form

Lay Distribution Order Request Form

HRO believes that you are the expert of your own experience and have the best understanding of your own community. Our goal is to provide access to low-barrier Naloxone, and other harm reduction supplies to those already serving their communities impacted populations. Please use the form below to request supplies. HRO sources naloxone through the Ohio Department of Health as well as other networks.
Date

MonthDayYear
Hour MinutesAM/PM Option
AGE GROUP (Choose only one)
Which of the following best describe(s) you? Please select all that apply.
Which of the following accurately describe(s) you?
*del*Which Ohio county you live in
PLEASE DO NOT UNHIDE! WE WILL LOSE PREVIOUS DATA IF WE DELETE THIS QUESTION. BUT I NEEDED TO CHANGE THE FORMAT OF THE QUESTION FOR THE WORKFLOW <3 KELSEY
In which Ohio county do you live?
Additional counties you wish to serve
Name

First NameLast Name
Email
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Organization or Agency?
Your Mailing Address where you will receive supplies

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Are you willing to take a 30 minute Lay Distribution Training?
Which type of training would best fit your needs?
Which Harm Reduction Supplies are you interested in receiving to distribute?
Please note: Only naloxone and fentanyl test strips are guaranteed. All other items are donation-based and subject to availability. Harm Reduction Ohio prioritizes requests from the most vulnerable communities with limited access to services.

IF THIS IS A ONE-TIME REQUEST *DO NOT SUBMIT THIS FORM*

Please use the following form for ONE-TIME bulk requests.

https://form.jotform.com/AmandaLynn_Reese/one-time-event-supply-request-form
Is there anything else you would like to tell us?
Should be Empty:

Lay Distribution Order Request Form