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Harm Reduction Survey
Welcome to NovaSalud's Harm Reduction Program, we are grateful that you selected our organization and we want to reassure our respect and support to you and your family. Bienvenido al Programa de Reduccion de Danos de NovaSalud, te agradecemos que hayas seleccionado nuestra organizacion y reafirmamos nuestro respeto y apoyo a ti y a tu familia. NovaSalud Prevention Team / Grupo de Prevencion de Novasalud
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Confidentiality is a top priority at NovaSalud. We are committed to maintaining the highest level of confidentiality with all of the information we receive from this website’s users. You may visit our privacy policy page at: www.novasaludinc.org/privacy-policy. ** La confidencialidad es un prioridad para NovaSalud. Estamos comprometidos a mantener el mas alto nivel de confidencialidad de la informacion que recibimos de los usuarios de este sitio web. Puedes revisar nuestra politica de privacidad en la pagina: www.novasaludinc.org/privacy-policy.
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I have read and agree with NovaSalud Privacy Policy ** Yo lei y estoy de acuerdo con la politica de privacidad de NovaSalud
I understand that the item must be picked up at NovaSalud Office after it is approved / Yo entiendo que el articulo tiene que ser recogido en la oficina de NovaSalud.
1-Date / Fecha
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2-Name/Nombre
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First
Middle
Last
3-Date of Birth / Fecha de Nacimiento
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MM
1
2
3
4
5
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10
11
12
DD
1
2
3
4
5
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11
12
13
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16
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19
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25
26
27
28
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30
31
YYYY
2025
2024
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
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1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
4-We need your address ** Necesitamos tu direccion
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Address Line 1
Address Line 2
City
--- Select state ---
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
5-Email/Correo Electronico
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6-Phone Number to notify you of the approval / Numero de telefono para notificarte de la aprobacion.
7-What is your sex at birth ** Cual es tu sexo al nacer:
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Female
Male
Transgender FtM
Transgender MtF
Other
8-How do you identify ** Como te identificas?
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Gay
Lesbian
Bisexual
Pansexual
Non-binary
Other
9-Which products you need? / Cuales productos necesitas?
Narcan
Fentanyl Strips
Both
10-Please confirm that you watched the video in step 1, identified as: "Please Watch this Video to Obtain Your Free Kit" ** Por favor confirma que vistes el video en el paso 2, identificado com: "Por favor ve este video para obtener tu kit gratis.":
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Yes/Si
No
11-Do you or a family member use prescription opioids like: Oxycodone, Oxycontin, Percocet, Vicodin, Fentanyl or Heroin ** Tienes un familiar que usa opioides recetados como: Oxycodone, Oxycontin, Percocet, Vicodin, Fentanyl o Heroina.
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Yes/Si
No
12-Have you or your family member overdosed on opioids in the past? ** Has tu o tu familiar tenindo una sobredosis en el pasado?
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Yes/Si
No
13-Comment or Message/ Comentario o Mensaje
14-For use of NovaSalud Employees/Para uso de empleados de NovaSalud
Product Sent/ Product Enviado
Please check all items below/Por favor marca todos los items abajo
Summary 1
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Video watched by client
Summary 2
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OD
Submit
