Harm Reduction Supply Delivery Form

hp_token

This a service provided by the Champaign-Urbana Public Health District. We only deliver to Champaign or Vermilion counties. Deliveries are scheduled on Monday thru Fridays between 9am and 4pm.

**** Starting IMMEDIATELY, deliveries to Vermilion county are limited to only Fridays.

Any information collected on this form is confidential.

If you have any questions or concerns, please email Joe Trotter.

* Indicates required question

What is your phone number? *

What is your gender? *

Male

Female

Non-binary

Other

What is your first initial? *

What is your date of birth? *

What is your mother's first initial? *

What is your zip code? *

What is your race? *

American Indian or Alaska Native

Asian

Black or African-American

Native Hawaiian or Other Pacific Islander

White

Hispanic or Latine

Prefer not to say

Do you need a participant card? *

Yes No

Delivery Details

What date do you want the supplies delivered? *

Date *

Time *

How do you want your supplies delivered?
Leave on my door step
Text you when we arrive
Call when you arrive
Knock or Ring door bell
Other

What address and city should the supplies go to? *

What city do you live in? *

How many of each of the following do you want?

29g Needles *
(Max 1,000)

31g Needles *
(Max 1,000)

Kits of Nasal Narcan *

Kits of Injectable Narcan *

Fentanyl test strips *

Xylazine (tranq) test strips *

Benzo test strips *

Smoking kits *

What other supplies do you want?
Tourniquets
Cookers
Cottons
Alcohol Pads
Band-aids
Condoms & Lube
Medium sharps container
Waters

Any other things to add?

Harm Reduction Supply Delivery

Champaign Urbana Public Health District

Delivery Details