Name, Address, Phone, and Health History (NAPH) Form Instructions
- This form is to be used at the time of an event that may require emergency medication to prevent illness.
- During an emergency, you may pick up medicine for up to 20 people but must complete information on the NAPH form for all individuals, including yourself.
- During an emergency, you will be directed by local media to bring this completed form to a point of distribution site (POD).
- The form will automatically download to your computer when you click on the link.
- It is a fillable form, which means that you will type your information directly into the form.
- After finishing the form, please save it to your computer and print the form.
- Please bring the form with you to the POD (point of distribution).
NAPH FORM LINK (Open the file in a PDF reader in order to access the fillable version of the form)
If you cannot view or use the fillable NAPH form, please follow this link to a form that you can print, fill out by hand, and bring with you to the POD (point of distribution).
PAPER NAPH FORM LINK