TN Campus Overdose Prevention and Response Project: Naloxone/Testing Strips Request Form

CHASCo has received opioid abatement funding to provide overdose education and naloxone/testing strips to all of our CHASCo members! We are partnering with SAFE Campuses to provide technical assistance to support our campuses with building up the infrastructure needed to provide effective overdose education and to distribute naloxone and testing strips. This form is to request Naloxone and/or testing strips for your campus programming.

Please consider keeping your requests at 250 units or lower unless your campus has created a plan to justify additional numbers. Campuses will have the opportunity to request additional naloxone each quarter once their current supply is depleted.

A quarterly report must be completed before additional Naloxone can be requested.

Please review the Title VI Policy Overview provided by CHASCo before you fill out your application.

Name

Title

College/University

Email Address

Shipping Address. Please include the address where you would like items shipped for your campus.

Phone Number

Approximate Student Population on Campus (Undergraduate and Graduate)

Have you reviewed the Title VI Slides linked in the paragraph above? This is mandatory to receive funding.

YesNo

How many units of Naloxone would you like to request for your campus? Campuses will have the opportunity to request additional naloxone each quarter once their current supply is depleted. A quarterly report must be completed before additional Naloxone can be requested.

How many Fentanyl Test Strips would you like to request for your campus?

How many Xylazine Test Strips would you like to request for your campus?

Would you like to order ONEboxes or other boxes for installation on your campus. Please indicate how many and what brand here.

Are there any other items you would like to request for your campus? Please indicate those items here along with quantities and where those items can be purchased.

By what date would you like the materials to be delivered?

Please describe your plan for providing overdose education and distributing Naloxone/testing strips for your campus. Please break down your request by distribution method (programming, targeted training, awareness event, AED, etc. - If you recently submitted a proposal as a part of the Overdose Prevention & Response Cohort, please just indicate that your proposal has been submitted. You do not need to inlcude that information here.

Campuses that receive this funding will be required to fill out an evaluation explaining how the Naloxone/strips were distributed on campus. This evaluation will be provided through Survey Monkey and distributed by the Director each quarter. - Please check the box to indicate that you understand an evaluation will be required quarterly.

Yes, I understand that an evaluation will be required for those who receive this funding.

Please share any technical assistance that you may need to meet your goals for this project.