Harm Reduction Kit Request Form

Harm Reduction Kit Request Form
Your requested Harm Reduction Kit will be ready for pick up at Jackson County Public Health within one business day of your request. Please plan to pick up your kit within three business days.

You may use a nickname, initials, or the randomly-generated order number (below) in the "name" field if you prefer to stay anonymous.

One kit includes:
- 1-3 boxes of nasal naloxone (Narcan) with instructions
- Fentanyl test strips (10-pack) with instructions
- Magnet and wallet card
- CPR face shield
- Printed treatment and recovery resources
- Drawstring bag
If you are requesting harm reduction supplies on behalf of an organization or are seeking more than 3 boxes of naloxone, please reach out directly to (816) 404-6493 or healthpromotions@uhkc.org.

Out of area? If you are outside the KC metro area, you can find a free naloxone resource near you in Missouri or nationwide.
Order number
What is today's date?*

MonthDayYear
Date
Name*
Your name will only be used to coordinate your Narcan kits for pick up. You may use a nickname, initials, or your order number (above).
What is your zip code?*
Type "NA" if you prefer not to answer.
What is your age?*

Under 18 years old18 - 24 years old25 - 34 years old35 - 44 years old45 - 54 years old55 - 64 years old65 - 74 years old75 years old or olderPrefer not to answer
What is your race?*

American Indian or Alaska NativeAsianBlack or African AmericanHispanic or LatinoMiddle Eastern or North AfricanNative Hawaiian or Pacific IslanderWhitePrefer not to answerOther
Do you identify as Hispanic or Latino/a/e?

Yes, Hispanic or Latino/a/eNo, not Hispanic or Latino/a/ePrefer not to answer
How many boxes of naloxone (Narcan) would you like?*
One box contains two (2) doses of nasal naloxone
Have you ever used naloxone before?

YesNoI don't know
Email
Email will only be used to notify you that your kit is ready for pick up and to send a satisfaction survey.
Phone Number
Please enter a valid phone number.
How did you hear about this program?

JCPH staffSocial mediaNews coverageResource listCommunity organizationOther
Signs of an overdose
- Blue (lighter skin tones) or gray (darker skin tones) lips and fingertips
- Pale, clammy skin
- Small, pinpoint pupils
- Slow heartbeat and slow, irregular, or stopped breathing
- Not responding to voice or touch
Para video en español: https://youtu.be/2YvTcpOejes?si=etK51cCmNnO_i4ir
How to use naloxone to save a life

Naloxone (Narcan) can reverse an opioid overdose. If someone has not used opioids, naloxone will have no effect on them. Naloxone is safe for use in adults and children.
1. If you suspect someone is overdosing, call 911. The dispatcher can give you support and help you keep time until paramedics arrive.
2. Tilt the person's head back by putting your hand under their chin. Insert the white tip of the naloxone nasal spray into their nostril.
3. Push the plunger down with your thumb until all of the spray is released into the nostril.
4. Remove the canister from their nose and roll the person onto their side into the recovery position.
5. Talk to the person and let them know what is happening.
6. If they don't wake up/come to after 3 minutes, give them another dose of naloxone.
Safer use = overdose prevention

If you are using substances, have a safety plan. A safety plan might include any of the following safer use tips.
- Never use alone. Call the Never Use Alone line for confidential, judgment-free support while you use: 877-696-1996.
- Test for fentanyl. The presence of fentanyl drastically increases the chances of accidental overdose. Use fentanyl test strips to keep yourself and others safe.
- Use new, clean needles every time. Don't share needles or works. If you have to reuse a needle, clean the syringe with cold, clean water and disinfect it with bleach for 2 minutes, then flush it out with cold, clean water again.
- Go slow, especially if you are changing the way you use (like switching from smoking to injecting) or if you haven't used in a few days. Even one day of not using can decrease your tolerance.
- Be careful when combining opioids with other "downers" like alcohol or benzos (such as Xanax or Klonopin). These combinations can increase the risk of overdose.
By checking this box, I attest that I have reviewed the educational information above, including signs of an overdose, how to administer Narcan, and factors that increase the risk of overdose. I can return to Jackson County Public Health to pick up more Narcan kits at any point.*

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