Harm Reduction Supply Request Form

Name/POC *

Organization or Coalition Name

Organization Type

Email *

Phone Number *

Delivery Address *

State *

City *

Zip Code *

I would like to request * Naloxone (4mg intranasal) Xylazine Test Strips Fentanyl Test Strips Deterra Drug Destruction Pouches (if available)

Number of Naloxone kits (2 doses/kit) you are requesting? *

Number of Xylazine Test Strips you are requesting? *

Number of Fentanyl Test Strips you are requesting? *

Number of Deterra Drug Destruction Pouches (if available) you are requesting? *

Do you need this by a certain date? *

Yes No

If so, date needed by:

I may also be interested in scheduling the following courses in my area, please send me more info. Naloxone Administration Training Opioid Awareness and Emerging Drugs None

Validation *