Facility/Agency/RCO Registration Form

Facility/Agency/RCO Registration Form
The Rural Opioid Harm Reduction for Justice-Involved Individuals (ROHR) project is collaborating with rural Georgia sheriff’s offices, confinement facilities, first responders, justice-involved individuals, and Recovery Community Organizations who work with justice-impacted groups to reduce the impact of the opioid epidemic. *

Our goal is to support your work through supplies, education, and resources.

Participating facilities can receive:
- Harm reduction supplies, such as naloxone (Narcan), for use in justice-involved individuals
- A print and digital resource guide that connects recently-released individuals and their family and friends to treatment, healthcare, and community-based services, both locally and statewide.
- Educational materials and training focused on opioid-related topics for facility staff and leadership
To get started, please complete the registration form below consisting of 31 questions. Once you complete your registration, we’ll reach out to coordinate your materials and support.

This project is delivered at NO COST to your facility or organization and is supported through the Georgia Opioid Crisis Abatement Trust.

*Please note that the harm reduction supplies offered under this project are not intended for distribution to the general public.

4. Primary Contact First and Last Name

First NameLast Name
Primary Contact Title
Primary Contact Email Address
example@example.com
Primary Contact Phone Number
Please enter a valid phone number.Format: (000) 000-0000.

5. Secondary Contact First and Last Name

First NameLast Name
Secondary Contact Title
Secondary Contact Email Address
example@example.com
Secondary Contact Phone Number
Please enter a valid phone number.Format: (000) 000-0000.

6. Confinement Facility/Agency/RCO Physical Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
7. Confinement Facility/Agency/RCO Mailing Address (if different from above)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
8. For the delivery of products, which is the best address above to use?

Other
9. Is there any additional information we need to know to ensure the products are delivered correctly?
10. What are you hours of operation/accept deliveries?

Section 5: About Your Community
27. Are there any local organizations, services, or potential partners you would recommend we connect with to support this project?
28. What types of support or resources are most needed to reduce opioid-related harm in your community? (Check all that apply)

Other
29. Is there anything else you would like us to know about your facility/agency, your community, or your support for this project?

Section 6: Next Steps
30. What questions or concerns do you have about the project?
31. How did you hear about this project?

Other
What’s Next?

Required Onboarding Discussion: A member of our team will be reaching out soon to go over the program and discuss your facility's harm reduction needs.

Access to Resources: You’ll receive an opioid harm reduction kit with statewide and local resource guides and harm reduction materials such as naloxone and/or fentanyl test strips (if requested).

Ongoing Support: Our team is available for any questions you may have, technical assistance, staff training, and policy development support.