Opioid Safety Coalitions -- American Opioid Project
Note: This form is open to opioid safety coalitions and nonprofits, as well as substance abuse prevention coalitions and nonprofits that cover opioids. The responses below may be posted on the American Opioid website and/or social media pages, in whole or in part. Questions may be directed to Jamal Khan at jamalkhan@americanopioid.org.
Sign in to Google to save your progress. Learn more
Email *
Name *
Title *
Coalition Name *
City or County *
State *
Briefly, how would you describe the opioid crisis in your region? *
What are your coalition's objectives? *
What are up to three major challenges your coalition faces in fulfilling its objectives? *
How much support have you received from government public health agencies, elected officials, and other nonprofit organizations? *
If you had a magic wand that allowed you to make any policy change you wanted to more effectively alleviate the opioid crisis in your area, what would that change be, and why? *
Are there any additional thoughts you would like to share? (optional)
Clear form
Never submit passwords through Google Forms.
This form was created inside of UC Berkeley. Report Abuse