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    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).

  • Section 1: Who Should We Contact?

  • Are you a first responder who does not work in a jail or prison?*
  • 3. Facility/Agency Type: (Check all that apply) FEDERAL:*
  • Facility/Agency Type: (Check all that apply) STATE:*
  • Facility/Agency Type: (Check all that apply) LOCAL*
  • Facility/Agency Type: (Check all that apply) COMMUNITY CONFINEMENT FACILITY*
  • Facility Type: (Check all that apply) JUVENILE*
  • What type of first responder agency best fits your organization?*
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • 8. For the delivery of products, which is the best address above to use?*
  • Section 2: About Your Facility/Agency

  • 11. What is your average length of stay for detainees?*
  • 12. Approximately what percentage of your population has substance abuse issues (estimated)?*
  • 13. Do you currently offer any substance use or behavioral support at your facility/agency?*
  • 13a. If you answered yes above, or are planning to implement, check all that apply:
  • 14. Do you currently have any external organizations or groups that provide on-site support or training (e.g., weekly AA/NA meetings)?*
  • 15. Do you currently have medical staff on-site?*
  • Section 3: What You're Doing Now

  • 16. Do you currently have naloxone (Narcan) for use in your facility/agency?*
  • 17. How frequently do you administer naloxone (Narcan) at your facility or through your agency?*
  • 18. Do you currently provide naloxone (Narcan) to individuals upon release or after contact with suspected high-risk individual?*
  • 19. Do you currently provide any harm reduction education to detainees or after contact with a suspected high-risk individual?*
  • 20. Do you provide individuals with resource information (e.g. housing, healthcare, recovery support, employment upon their release or after an interaction?*
  • 21. Do you have any policies regarding Medications for Opioid Use Disorder (MOUD)?*
  • 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.*
  • 22b. Would you like to receive printed informational/educational Materials, Harm Reduction Supplies and/or Resources?*
  • ROHR Products:

    Categories:All
    All
    Printed Informational/Education Materials (click image to enlarge)
    Harm Reduction Supplies and Resources (click image to enlarge)
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        Printed Informational/Education Materials (click image to enlarge)
        Opioid Tolerance Rack Card. An informational card that educates staff and detainees about the increased risk of overdose following release from confinement.
        Opioid Tolerance Rack Card

        An informational card that educates staff and detainees about the increased risk of overdose following release from confinement.

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

        A tailored list of trusted resources to find the support you or your loved one needs across the state of Georgia.

        Free$ Free
          
        County-Specific Resource Guide. A tailored list of trusted resources to find the support you or your loved one needs within a specific county of Georgia. Please note: Facilities may request a county-specific resource guide as part of this project. Not all county guides are currently available, as some are still in development. While we will do our best to fulfill requests, availability is limited and we may not be able to reach every county within the project timeline.
        County-Specific Resource Guide

        A tailored list of trusted resources to find the support you or your loved one needs within a specific county of Georgia. Please note: Facilities may request a county-specific resource guide as part of this project. Not all county guides are currently available, as some are still in development. While we will do our best to fulfill requests, availability is limited and we may not be able to reach every county within the project timeline.

        Free$ Free
          
        Naloxone Administration Trifold. A user-friendly reference on proper nasal naloxone administration.
        Naloxone Administration Trifold

        A user-friendly reference on proper nasal naloxone administration.

        Free$ Free
          
        Naloxone Readiness Best Practices Flyer. Guidelines for availability, accessibility, and training
        Naloxone Readiness Best Practices Flyer

        Guidelines for availability, accessibility, and training

        Free$ Free
          
        Fentanyl Test Strip Instructional Pamphlet. How & when to use a fentanyl test strip to reduce opioid overdoses.
        Fentanyl Test Strip Instructional Pamphlet

        How & when to use a fentanyl test strip to reduce opioid overdoses.

        Free$ Free
          
        Harm Reduction Supplies and Resources (click image to enlarge)
        Naloxone. Includes naloxone nasal spray - Each box contains 2 4mg-doses.
        Naloxone

        Includes naloxone nasal spray - Each box contains 2 4mg-doses. 

        Free$ Free
          
        Fentanyl Test Kits. These test kits are are highly sensitive, accurate (96-100%), and easy-to-use tools for detecting fentanyl in powders, pills, and liquids. Each box contains 100 tests
        Fentanyl Test Kits

        These test kits are are highly sensitive, accurate (96-100%), and easy-to-use tools for detecting fentanyl in powders, pills, and liquids. Each box contains 100 tests

        Free$ Free
          
        Box Narcotics Lock Clear Top/ Plastic 6-1/4x7-1/4x1-7/8. Medication lock boxes are secure containers designed to store medications and prevent unauthorized access.
        Box Narcotics Lock Clear Top/ Plastic 6-1/4x7-1/4x1-7/8

         Medication lock boxes are secure containers designed to store medications and prevent unauthorized access.

        Free$ Free
          
        Drug Disposal Pouch. A 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.
        Drug Disposal Pouch

        A 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$ Free
          
        Release Bag requests are currently on hold. Please check back soon.. Includes 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)
        Release Bag requests are currently on hold. Please check back soon.

        Includes 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$ Free
          
        Leave-Behind Bag. Includes 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.
        Leave-Behind Bag

        Includes 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$ Free
          
        Lock Box Narcotics  Dimensions - 8.75 in x 6 in x 7.25 in. Medication lock boxes are secure containers designed to store medications and prevent unauthorized access.
        Lock Box Narcotics Dimensions - 8.75 in x 6 in x 7.25 in

         Medication lock boxes are secure containers designed to store medications and prevent unauthorized access.

        Free$ Free
          
        Total
        $0.00$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:*
      • 23. What is your main motivation for participating in this project?*
      • Section 5: About Your Community

      • 27. What are the biggest challenges you face related to opioid use in your community? (Check all that apply)*
      • 28. What types of support or resources are most needed to reduce opioid-related harm in your community? (Check all that apply)*
      • Section 6: Next Steps

      • 30. What is your preferred timeline for getting started?*
      • 32. How did you hear about this project?*
      • 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.

      • 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:

      • Please select today's date*
         - -
      • Thank you for completing the project registration form. Once this form is received by our office, our staff will reach out to you directly about the next steps.

        You must click 'SUBMIT' to proceed with registration. If you have any questions, please reach out to the IHLA at (912) 478-0302 or ihla@georgiasouthern.edu.

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