Lay Distributor Form

Bulk & 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)

< 1415 - 2425 - 3435 - 4445 - 5455 - 64> 65PREFER NOT TO SAY
Which of the following best describe(s) you? Please select all that apply.

Asian or Pacific IslanderBlack or African AmericanHispanic or LatinxMiddle Eastern or North AfricanNative AmericanWhite or CaucasianOtherPREFER NOT TO SAY
Which of the following accurately describe(s) you

FemaleMaleNon-BinaryTransgenderIntersexGender non-conformingOther not listedPREFER NOT TO SAY
County you live in*
Additional counties you wish to serve
Name*

First NameLast Name
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
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?*

YesNo
Which type of training would best fit your needs?

OnlineIn Person
Which Harm Reduction Supplies are you interested in receiving to distribute?

Intramuscular Naloxone4mg Nasal Naloxone (Narcan or Generic)8mg Nasal NaloxoneSafer Sex SuppliesSafer Smoking SuppliesSafer Snorting SuppliesSterlie SyringesDeterra BagsAnti-Stigma LiteraturePersonal Hygiene KitsMenstrual Hygiene KitsFentanyl Test StripsWound Care SuppliesFlyersStickersHarm Reduction Literature
Is there anything else you would like to tell us?
Should be Empty:

Bulk & Lay Distribution Order Request Form