Pitt County Forms Center

2.  
   
   

   201 Government Circle, Greenville, NC 27834  |  Telephone: 252-902-2324

   Opioid Settlement Spotlight Nomination

   
   _{All submissions will be reviewed. While not every story can be posted, each nomination helps us recognize and celebrate the impact of this important work. Selected stories may be highlighted in public reports, community meetings, or awareness campaigns to inspire ongoing collaboration and accountability. Direct identification may be withheld upon request or to protect the privacy of individuals and organizations involved.}

4. Nomination Information
6. Person, Agency or Organization Name*
8. Web Address
9. Phone Number
10. Email Address
12. Address

    Local Contact Address (if available, for national or state organizations)

14. City
15. State
    -- Select One --AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming
16. Zip Code
18. Additional Online & Social Media Links
20. Strategy Area of Impact*

    1. Collaborative Strategic Planning
    2. Evidence-Based Addiction Treatment
    3. Recovery Support Services
    4. Recovery Housing Support
    5. Employment-Related Support
    6. Early Intervention

    1. Naloxone Distribution
    2. Medical Disposal & Syringe Services Programs
    3. Criminal Justice Diversion Programs
    4. Re-Entry Programs
    5. Addiction Treatment for Incarcerated Persons
    6. Data & Evaluation
22. Nomination Testimonial or Impact Story Information*
24. Submitted By Information

26. The information below is not required and is only provided to PCPH for informational purpose incase we have questions. It will not appear with the listing. For contact information that the public will see, use the section above.

28. Affiliation with Nomination*
29. First Name*
31. Phone Number*
32. Email Address*
34. Further Information, Details or Comments (About Yourself, the Organization or Anything Else You’d Like Us to Know)
Leave This Blank:


36. Submit

* indicates a required field