If you are an individual requesting a single unit of Narcan (nasal spray) please visit: https://redcap.uthscsa.edu/REDCap/surveys/?s=8NDKCYKXJW
Organization Request for Naloxone:
A note on terminology: We are able to distribute naloxone in two formulations and refer to those as such: 1. Intramuscular (IM) naloxone* (administered via syringe) and; 2. Intranasal (IN) naloxone (commonly called "Narcan" and administered via nasal spray)
*IM naloxone is only available to organizations; not individuals - please contact us directly for more information.
Is this your first-time ordering naloxone (brand name: Narcan) from Naloxone Texas (formerly MoreNarcanPlease)?
* must provide value
Yes
No
What is the name of your institution or organization?
* must provide value
Primary group
* must provide value
Law Enforcement/EMS (Choose One)
* must provide value
Corrections- Jail
Corrections- Prison
Criminal Justice Organization
Drug Court
Fire/EMS
LE- Police/Sheriffs/State
Parole
Probation
Hospital (Choose One)
* must provide value
Hospital Inpatient
ED/ER
Hospital Outpatient
Education (Choose One)
* must provide value
Government Agency (Choose One)
* must provide value
Substance/Mental Health Clinics (Choose One)
* must provide value
Other (Choose One)
* must provide value
Which of the following best represents you or your institution? Select all that apply.
* must provide value
What are the counties of the areas you commonly serve?
County
* must provide value
Which of these groups are you supplying naloxone to? Select all that apply.
* must provide value
Distribution "Primary Distribution" refers to those doses of naloxone that you distribute directly to individuals likely to witness and respond to an overdose. "Secondary Distribution" refers to those doses of naloxone that you distribute to individuals who then distribute to people in their network likely to witness and respond to an overdose.
About what percentage of this naloxone do you intend for primary distribution?
* must provide value
About what percentage of this naloxone do you intend for secondary distribution?
* must provide value
What specific steps do you take to increase the likelihood that naloxone will end up in the hands of those who are most likely to witness and respond to an overdose?
* must provide value
How do you track and report secondary distribution of naloxone to other entities or individuals?
Do you regularly access naloxone from sources other than this website?
Yes
No
About what percentage of your total supply of naloxone comes from other sources?
Based on your own tracking and/or local data you are aware of, how many opioid-related overdoses occur in your service area each year?
* must provide value
Based on your own tracking and/or local data you are aware of, how many opioid-related overdoses are reversed in your service area each year?
* must provide value
Are you/your institution tracking opioid related overdoses?
* must provide value
Yes
No
Are you/your institution tracking reversals of opioid related overdoses?
* must provide value
Yes
No
Please provide contact and shipping information for your batch request:
First Name:
* must provide value
Last Name:
* must provide value
Phone:
* must provide value
Email:
* must provide value
Street Address: (P.O. Box shipping is NOT available)
* must provide value
City:
* must provide value
State:
* must provide value
Texas
This program is state funded by the Texas Health and Human Services Commission; we are unable to accept out of state requests.
Distribution County:
* By selecting a county below; you are agreeing that the naloxone received from this request will be distributed to individuals within that county.
* must provide value
Anderson County Andrews County Angelina County Aransas County Archer County Armstrong County Atascosa County Austin County Bailey County Bandera County Bastrop County Baylor County Bee County Bell County Bexar County Blanco County Borden County Bosque County Bowie County Brazoria County Brazos County Brewster County Briscoe County Brooks County Brown County Burleson County Burnet County Caldwell County Calhoun County Callahan County Cameron County Camp County Carson County Cass County Castro County Chambers County Cherokee County Childress County Clay County Cochran County Coke County Coleman County Collin County Collingsworth County Colorado County Comal County Comanche County Concho County Cooke County Coryell County Cottle County Crane County Crockett County Crosby County Culberson County Dallam County Dallas County Dawson County Deaf Smith County Delta County Denton County DeWitt County Dickens County Dimmit County Donley County Duval County Eastland County Ector County Edwards County El Paso County Ellis County Erath County Falls County Fannin County Fayette County Fisher County Floyd County Foard County Fort Bend County Franklin County Freestone County Frio County Gaines County Galveston County Garza County Gillespie County Glasscock County Goliad County Gonzales County Gray County Grayson County Gregg County Grimes County Guadalupe County Hale County Hall County Hamilton County Hansford County Hardeman County Hardin County Harris County Harrison County Hartley County Haskell County Hays County Hemphill County Henderson County Hidalgo County Hill County Hockley County Hood County Hopkins County Houston County Howard County Hudspeth County Hunt County Hutchinson County Irion County Jack County Jackson County Jasper County Jeff Davis County Jefferson County Jim Hogg County Jim Wells County Johnson County Jones County Karnes County Kaufman County Kendall County Kenedy County Kent County Kerr County Kimble County King County Kinney County Kleberg County Knox County La Salle County Lamar County Lamb County Lampasas County Lavaca County Lee County Leon County Liberty County Limestone County Lipscomb County Live Oak County Llano County Loving County Lubbock County Lynn County Madison County Marion County Martin County Mason County Matagorda County Maverick County McCulloch County McLennan County McMullen County Medina County Menard County Midland County Milam County Mills County Mitchell County Montague County Montgomery County Moore County Morris County Motley County Nacogdoches County Navarro County Newton County Nolan County Nueces County Ochiltree County Oldham County Orange County Palo Pinto County Panola County Parker County Parmer County Pecos County Polk County Potter County Presidio County Rains County Randall County Reagan County Real County Red River County Reeves County Refugio County Roberts County Robertson County Rockwall County Runnels County Rusk County Sabine County San Augustine County San Jacinto County San Patricio County San Saba County Schleicher County Scurry County Shackelford County Shelby County Sherman County Smith County Somervell County Starr County Stephens County Sterling County Stonewall County Sutton County Swisher County Tarrant County Taylor County Terrell County Terry County Throckmorton County Titus County Tom Green County Travis County Trinity County Tyler County Upshur County Upton County Uvalde County Val Verde County Van Zandt County Victoria County Walker County Waller County Ward County Washington County Webb County Wharton County Wheeler County Wichita County Wilbarger County Willacy County Williamson County Wilson County Winkler County Wise County Wood County Yoakum County Young County Zapata County Zavala County
Distribution County
* By selecting a county below you are agreeing that the naloxone received from this request will be distributed to individuals within that county.
Zip Code:
* must provide value
Who will be the intended user for this naloxone request?
Please briefly explain how you heard of this service:
How many units (each unit contains 2 doses) of naloxone would you like to request? Orders must be in increments of 12 and limited to 108 units a month.
As we near the closing of the state fiscal year, we are temporarily reducing max order sizes to 48 units. This reduction is temporary. If you have an emergency need and do need higher amounts, please email our project team to discuss further.
* must provide value
12
24
36
48
60
72
84
96
108
252
How many units (each unit contains 2 doses) of naloxone would you like to request? Orders must be in increments of 12 and limited to 108 units a month.
* must provide value
12
24
36
48
60
72
84
96
108
120
132
144
156
168
180
252
500
504
Thank you for your responses! Please visit Naloxone Texas for more information on our efforts.