APPENDIX - NALOXONE ORDER FORM (002).DOCX

Appendix:
MARICOPA COUNTY DEPARTMENT OF PUBLIC HEALTH - NALOXONE 
KIT ORDER FORM
Page 1 of 2
COPY OF THE ONLINE NALOXONE ORDERING FORM 
All requests must be submitted through the online form. 
I. INSTRUCTIONS
Your department’s participation is requested to support this life-saving effort. Only the 
designated Department Designee should complete this form. A Designee is a staff 
member chosen by the Department Director to:

Maintain accurate records of naloxone kits.

Order additional naloxone as required.

Monitor expiration dates.

Ensure naloxone kits are accessible and properly stored.
II. DESIGNEE CONFIRMATION
1. ☐ I am the designated representative for my department.
III. DEPARTMENT INFORMATION AND PARTICIPATION
1. Department Name:  Enter the official name of your department.
2. Department Participation
   ☐ Yes, our department would like to participate in the Naloxone 
Program.
   ☐ No, we are not interested in participating at this time.
IV.PROGRAM OVERVIEW
Purpose: To provide naloxone kits to reduce overdose deaths in Maricopa County.
Kit Contents:

Two (2) doses of nasal NARCAN (brand name of naloxone)

Carrying case

Instructions for use

List of emergency assistance resources

Gloves
Training Requirement: All staff involved in naloxone administration must complete the 
Opioid Overdose and Response Training available through Workday. Training should be 
completed before naloxone kits are distributed.
V. REQUEST FOR NALOXONE KITS
Naloxone kits are prioritized for staff and public-facing locations. Consider the following 
when requesting kits:

Front desk or reception areas

Security personnel

Outreach and engagement roles

Appendix:
MARICOPA COUNTY DEPARTMENT OF PUBLIC HEALTH - NALOXONE 
KIT ORDER FORM
Page 2 of 2
1.    Enter the number of kits needed (based on staffing levels and need): _____
VI. CONTACT INFORMATION
1. Designee Contact Details
   Name: Provide your full name.
   Title: Enter your job title.
   Email Address: Provide your work email.
   Phone Number: Enter your direct contact number.
2. Naloxone Pickup Contact
   Will you be the primary contact for naloxone pickup?
   ☐ Yes - I will coordinate the pickup of naloxone.
   ☐ No - Provide an alternate contact's details below:

Alternate Contact Name

Email Address

Phone Number
VI.NEXT STEPS
Click “Submit” to finalize your request. After submitting your request, you will receive a 
confirmation email. Public Health Staff will email the Naloxone Pickup Contact to 
coordinate pickup.
If you need assistance during this process, contact SubstanceUse@maricopa.gov. 
Version 1. Created 11.1.2024