The Baltimore City Health Department's Naloxone Training Request Form

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

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.

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? *

Traditional Naloxone Training (1 hour)

Train the Trainer session (1.5 hours) *become a trainer*

Would you prefer Zoom or an in-person training? *

Zoom

In-person

Are you requesting naloxone? If so, how many kits?

Type of Facility *

IOP

Outpatient Facility

Community Group or Organization

Mental Health Services

Individual

Government Entity

Law Enforcement /Judicial System

Senior Centers or Senior Living Apartments

Other:

Is this training for patients or clients with lived experience, family and friends, or staff of the facility? *

Staff

Clients

Neighbors

Other:

Number of Participants *

1-10

11-20

21-30

31-40

More than 40

Is your organization interested in becoming an Overdose Response Program?

Yes

Maybe

Clear selection

Is your organization interested in becoming a naloxone distribution site?

Yes

Maybe

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

YYYY

Proposed Training Time

Time

For in person trainings, please provide parking instructions

Please note any important information below

Send me a copy of my responses.

Submit

Clear form

Never submit passwords through Google Forms.

reCAPTCHA

Privacy Terms

This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy

Forms