Required fields are marked with asterisks (*)

Naloxone Distribution Eligibility Form

To learn more about eligibility please review: Ontario Take-Home Naloxone Programs | ontario.ca

Agency Contact Information

Agency Name:

First Name:

Last Name:

Address:

City:

Postal Code:

Email:

Agency Type

Please describe the target population that your agency serves:

Has your agency had requests for Naloxone?:

Yes

Does your agency reach priority populations where there is known drug use/opioid activity?:

Yes

Does your agency work directly with populations at risk of overdose?:

Yes

Can your agency commit to reporting to the HKPR District Health Unit quarterly?:

Yes

Submit below any additional information you would like the Haliburton Kawartha Pine Ridge district Health Unit to know about your naloxone distribution:

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