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).
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