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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).