The code block below illustrates how one might use # and // as comments in your logic and calculations.

This value you provided is not a number. Please try again.

This value you provided is not an integer. Please try again.

The value entered is not a valid Vanderbilt Medical Record Number (i.e. 4- to 9-digit number, excluding leading zeros). Please try again.

The value you provided must be within the suggested range

The value you provided is outside the suggested range

This value is admissible, but you may wish to double check it.

The value entered must be a time value in the following format HH:MM within the range 00:00-23:59 (e.g., 04:32 or 23:19).

This field must be a 5 or 9 digit U.S. ZIP Code (like 94043). Please re-enter it now.

This field must be a 10 digit U.S. phone number (like 415 555 1212). Please re-enter it now.

This field must be a valid email address (like joe@user.com). Please re-enter it now.

The value you provided could not be validated because it does not follow the expected format. Please try again.

Required format:

NgNm3dVbzz97tnX6IfQFPprbunGk2iT5xFknfqWZDgnKnqI5E5uai4fN8L6TVbcTDtpQU6duHJdmSCC3YiZxKTTmyVpoxhVBqC9QHA3qGcwi2XKY

Naloxone (Narcan) Kit Request Form

Naloxone (Narcan, Kloxxado) is a life-saving medication that can reverse an overdose from opioids including heroin, fentanyl, and prescription opioid medications. If you or someone you know is at an increased risk for opioid overdose, you should carry naloxone and keep it at home. Naloxone has no effect on someone not using opioid drugs. Naloxone kits are available to all Mississippi residents with no out of pocket cost.

Please complete the following survey to receive your free naloxone kit. This survey will take approximately 14 minutes to complete. You will be required to watch a short training video that is provided at the end of this survey. Kits will be mailed to the address you provide.

All information will be kept confidential. Answers will not be shared with any personal identifying information. Your responses will only be used to identify areas of need and to help us to improve services offered by our program.

If you have questions or need assistance with the survey, please contact the Mississippi State Department of Health at 601-713-3457 or email naloxone@msdh.ms.gov. For more information about the opioid epidemic in Mississippi visit ODFree.org.

*Due to high demand and limited product availability, the time to process requests may be longer than usual. Requests will be filled in the order that they were received.*

Time started

* must provide value

M-D-Y H:M

Age

View equation

Please provide the following information. All information is kept confidential.

* must provide value

First Name:

Last Name:

Physical Address (cannot ship to P.O. boxes):

City/Town:

County:

State:

Zip/Postal Code:

Phone Number:

* must provide value

I would like my kit mailed to the address provided above. Kits cannot be mailed to a P.O. Box.

I would prefer to pick up my naloxone kit at a health department.

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Please allow 3-5 business days for the processing and shipment of your kit.

*Due to high demand and limited product availability, the time to process requests may be longer than usual. Requests will be filled in the order that they were received.*

If you would like to receive FedEx tracking information for your kit, please provide an e-mail:

Please select the county health department where you would like to pick up your kit.

For locations and hours, please visit MSDH County Health Departments.

* must provide value

Date of Birth

* must provide value

M-D-Y

With which gender do you personally identify?

* must provide value

Male

Female

Non-binary

Prefer not to answer

Other:

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Do you consider yourself to be transgender?

* must provide value

Yes

Prefer not to answer

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With which racial group(s) do you identify?

Check all that apply

* must provide value

White or Caucasian

Black or African American

Asian or Asian American

American Indian or Alaska Native

Native Hawaiian or other Pacific Islander

Other:

Are you of Hispanic, Latino, or of Spanish origin?

* must provide value

Yes No

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You have selected an option that triggers this survey to end right now.

To save your responses and end the survey, click the 'End Survey' button below. If you have selected the wrong option by accident and/or wish to return to the survey, click the 'Return and Edit Response' button.