Facility/Agency Registration Form

Facility/Agency 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 other 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 32 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 State Abatement Trust (GOCAT#408).

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.

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.

6. Confinement Facility/Agency Physical Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
7. Confinement Facility/Agency 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?*

Physical AddressMailing AddressOther
9. Is there any additional information we need to know to ensure the products are delivered correctly?

Section 4: What Are You Interested In?
22a. Would you like Digital Education Materials? **After submitting this form, please check your spam folder for an email from noreply@jotform.com if you selected "Yes" and did not receive an email in your inbox with "Educational Materials" in the subject line.*

YesNo
22b. Would you like to receive printed informational/educational Materials, Harm Reduction Supplies and/or Resources?*

YesNo
ROHR Products:
Categories:All

All

Printed Informational/Education Materials (click image to enlarge)

Harm Reduction Supplies and Resources (click image to enlarge)
prevnext( X )
Printed Informational/Education Materials (click image to enlarge)

Window ClingA window cling that can be displayed in your agency’s window to indicate that naloxone is available for those who need it
$ Free Quantity



Opioid Tolerance Rack CardAn informational card that educates staff and detainees about the increased risk of overdose following release from confinement.
$ Free Quantity



Statewide Resource FlyerA tailored list of trusted resources to find the support you or your loved one needs across the state of Georgia.
$ Free Quantity



PostcardInternal-use informational postcards intended for confinement facilities.
$ Free Quantity



County-Specific Resource GuideA tailored list of trusted resources to find the support you or your loved one needs within a specific county of Georgia.
$ Free Quantity



Naloxone Administration TrifoldA user-friendly reference on proper nasal naloxone administration.
$ Free Quantity



Harm Reduction Supplies and Resources (click image to enlarge)

NaloxoneIncludes naloxone nasal spray - 2 4mg-doses.
$ Free Quantity



Fentanyl Test StripsFentanyl test strips (FTS) are small paper strips used as a harm-reduction tool to detect the presence of fentanyl in a drug sample before it is consumed.
$ Free Quantity



Medication Lock BoxesMedication lock boxes are secure containers designed to store medications and prevent unauthorized access.
$ Free Quantity



Drug Disposal PouchA safe medication disposal pouch is a safe and effective way to destroy and properly dispose of unused, unwanted, or expired medications. Drug disposal systems destroy pills, patches, and liquids — preventing misuse and protecting the environment.
$ Free Quantity



Release BagsIncludes naloxone nasal spray, fentanyl test strips, and educational material,s and can be handed out to detainees upon their release from confinement. (available for jails only)
$ Free Quantity



Leave-Behind BagIncludes naloxone nasal spray, fentanyl test strips, and educational materials, and will be provided to individuals on-site after the first responder has concluded their response activities.
$ Free Quantity



Total

$0.00
22c. Are you interested in access to training services for your staff or detainees? IF so please indicate which training you would prefer below:*

5-minute basic naloxone administration educational video (online)60-minute training for staff (online) for harm reduction education and naloxone administration60-minute training for staff (in-person) for harm reduction education and naloxone administration3-4 hour 'Train the Trainer' to deliver harm reduction education and naloxone administration training (in-person)Harm reduction training for detainees or other high-risk individuals (online)Harm reduction training for detainees or other high-risk individuals (in-person)Not sure, I would like to discuss with someone.None
23. What is your main motivation for participating in this project?*

Reduce overdose deathsImprove community safetyBetter support for individuals with substance abuse issuesProfessional development for staffOther
24. What concerns, if any, do you have about participating in this project?

Section 6: Next Steps
30. What is your preferred timeline for getting started?*

As soon as possibleWithin 1 monthWithin 3 monthsNeed more time to prepareOther
31. What questions do you have about the project?*
32. How did you hear about this project?*

Direct outreach from the research teamReferral from another facilityProfessional associationOther
What’s Next?

Onboarding Call: A member of our team will be reaching out soon to schedule a brief call to go over the program and answer any questions.

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.

Ongoing Support: Our team is available for technical assistance, staff training, and policy development support.

Facility/Agency Registration Form

Section 1: Who Should We Contact?

Section 2: About Your Facility/Agency

Section 3: What You're Doing Now

Section 4: What Are You Interested In?

Section 5: About Your Community

Section 6: Next Steps

Please check each box below to indicate your acceptance of the terms and conditions. By requesting naloxone and/or fentanyl test strips, you agree that the following terms and conditions will become immediately effective: