If someone is experiencing a life-threatening situation, call 911... if someone is not breathing, call 911... if someone is seizing/convulsing, call 911... if someone is unconscious, call 911...if someone is bleeding profusely, call 911... if someone is experiencing a life-threatening situation, call 911...
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Program Request Form

Before placing your order please take a moment to complete the survey below. You will be directed to the program request page once you have completed the survey. Your participation will assist us in providing quality services to communities across the state. Please check your response for each question.
Gender
Is English your first language?
Have you attended a poison prevention presentation within the last year?
Have you ordered poison prevention educational materials within the last year?
Have you called the NJ Poison Control Center Help Hotline (1-800-222-1222) within the last year?
Are you aware of the following NJ Poison Control Center services?
Public Outreach Services - Poison Prevention Presentations/Workshops
Poison Prevention Education Materials
Professional Education Services
Poison Help Hotline for Emergency Assistance
Poison Help Hotline for Information on Poison Prevention
Have you EVER contacted the NJ Poison Control Center to utilize any of the following services?
Public Outreach Services - Educational Presentations
If yes, please check contact method(s)
Poison Prevention Education Materials
If yes, please check contact method(s)
Professional Education
If yes, please check contact method(s)
Poison Help Hotline for Emergency Assistance
If yes, please check contact method(s)
Poison Help Hotline for Information on Poison Prevention
If yes, please check contact method(s)
Would you contact the NJ Poison Control Center in the FUTURE to utilize the following services?
Public Outreach Services - Educational Presentations
If yes, please check contact method(s)
Poison Prevention Education Materials
If yes, please check contact method(s)
Professional Education
If yes, please check contact method(s)
Poison Help Hotline for Emergency Assistance
If yes, please check contact method(s)
Poison Help Hotline for Information on Poison Prevention
If yes, please check contact method(s)