OUTREACH SIGN-IN & OUT ROSTER
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Name *
Location *
Date *
MM
/
DD
/
YYYY
Use drugs? *
Received naloxone kit? *
Received fentanyl test strips? *
Referral *
YES
NO
Substance use treatment
Mental Health Care
Health Care
Housing
Food
HIV or Hep treatment
Business owner or employee? *
Other
Notes
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