The Baltimore City Health Department's Naloxone Training Request Form

Welcome to the Baltimore City Health Department Naloxone Training Request Form.  
Please contact Rania Mohamed, rania.mohamed@baltimorecity.gov, for any questions, comments, or concerns about your training request.

These requests will be fulfilled by the Overdose Prevention Team of the Baltimore City Health Department. Please allow at least 1-3 business days for a response from our team, and schedule your training at least 7 business days before the proposed date. This allows us to contact your team to schedule a new date if we are unavailable.
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Email *
Name and Title of Requester *
Phone Number *
Email Address *
Name of Facility *
Address of Facility *
Has there been a history of overdose in or around your facility? If not, is your facility located in a high-risk area? *
What type of training are you requesting? *
Would you prefer Zoom or an in-person training? *
Are you requesting naloxone? If so, how many kits?
Type of Facility *
Is this training for patients or clients with lived experience, family and friends, or staff of the facility? *
Number of Participants *
Is your organization interested in becoming an Overdose Response Program?
Clear selection
Is your organization interested in becoming a naloxone distribution site?
Clear selection
Has anyone from your facility administered naloxone? If yes, has it been reported to an official entity?
Priority of training *
Very high
Very low
Proposed Training Date 
MM
/
DD
/
YYYY
Proposed Training Time
Time
:
For in person trainings, please provide parking instructions
Please note any important information below
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