CDPH Naloxone Grant Program Application

California Department of Public Health
Safe and Active Communities Branch
Naloxone Grant Program

REQUEST FOR APPLICATIONS (RFA #16-10967):
Naloxone Distribution Projects

Application

Please complete and submit this application for the Naloxone Grant Program as soon as possible, but no later than May 1, 2017 in order to initiate the development of a grant agreement with CDPH.

Please send questions by April 17, 2017 to ngp@cdph.ca.gov.

Please provide the following information:

1. Local Health Department *This question is required.

2. Health Officer Information *This question is required.

Name
Phone Number
E-mail Address

3. Name of Grantee (Legal Business Name) *This question is required.

4. Principal Investigator (PI) Information *This question is required.

Name
Address 1
Address 2
City, Zip
Phone
FAX
E-mail

5. Person to Direct Inquiries to: *This question is required.

Name
Address 1
Address 2
City, Zip
Phone
FAX
E-mail

6. Person Authorized to Sign the Final Grant Agreement on Behalf of Your Agency *This question is required.

Name
Title

7. Your Organization's DEA Number *This question is required.

8. Address associated with your DEA Number (This address will be used for shipment of naloxone product.) *This question is required.

Address 1
Address 2
City, Zip