Opioid Disaster Declaration Request Form

Opioid Disaster Declaration Request Form
Submit a request for official recognition and support regarding an opioid-related disaster impacting your community or organization.
Organization Name
Official Contact Person (Full Name)
First NameLast Name
Contact Email Address
example@example.com
Contact Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Incident/Disaster Location (Address)
Street Address
Street Address Line 2
CityState / ProvincePostal / Zip Code
Date the Opioid Disaster Began or Was Identified
MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Please describe the opioid-related disaster and circumstances leading to this request.
Describe the impact of the opioid disaster on your community or organization.
What actions have already been taken to address the situation?
What resources, support, or assistance are you requesting?
Upload any supporting documentation (e.g., reports, news articles, data).
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Authorized Representative Signature
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