New York State Department of Health OPIOID OVERDOSE EDUCATIONAL MATERIALS ORDER FORM

New York State Department of Health
OPIOID OVERDOSE EDUCATIONAL MATERIALS ORDER FORM

Instructions for ordering bulk materials for New York State residents:

· Please circle only one (1) quantity per publication.

· Complete the address label on the last page. Be sure to print clearly. ALL orders must include a street mailing address. Bulk order cannot be delivered to Post Office boxes.

You can:

· Fax orders to 518-465-0432.

· Mail orders to: New York State Department of Health Distribution Center, 21 Simmons Lane, Albany, NY 12204; or

· Email orders to: .

Title / Language / Code # / Quantity
(circle one)
See An Overdose? Call 911 Immediately! This palm card explains how to recognize an opioid overdose and what life-saving steps to take when you witness one. It highlights New York State’s “911 Good Samaritan” law, which protects people from prosecution for drug or alcohol possession if they seek help for an overdose (palm card). 12/12. / English / 0226 / 25 50 100
Spanish / 0227 / 25 50 100
See An Overdose? Call 911 Immediately! Poster version contains all of the information described in the palm card above (poster). 12/12. / English / 0230 / 10 25 50
Spanish / 0231 / 10 25 50
Stop Prescription Pain Medication Misuse. This
palm card warns about the dangers of misusing prescription pain medications. It encourages readers to keep medications in a place at home where teens and other cannot access them (palm card). 3/12. / English / 0266 / 25 50 100
Spanish / 0267 / 25 50 100

Address Label (please print or type)

Name
Organization (if applicable)
Street Address
City
/ State / Zip Code
Telephone / E-mail

Delivery:

· Please allow three (3) to four (4) weeks for delivery.

· Order may not be picked up from the Distribution Center in Albany.

· Bulk orders cannot be delivered to Post Office boxes. Be sure to include a street address on the mailing label below.

1/2013