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Gun Lock Order Form
Thank you for your interest in ordering gun locks. Intermountain Health makes gun locks available as a part of its efforts to reduce suicide and accidental injury in Colorado, Idaho, Montana, Nevada, Utah, and Wyoming.

Turnaround time is typically 10-14 days.

Basic Information

Today's Date (mm/dd/yyyy)

Date gunlocks are needed in hand (if needed by a certain date for a specific event)(optional)(mm/dd/yyyy)

If this request if for distribution at an event, what is the name of the event? (if not, leave blank)

First Name

Last Name

Email Address

Preferred Phone Number

Which area in Colorado?
Western Slope: St. Mary's
Front Range: St. Joseph Hospital, Lutheran Hospital, Good Sam Hospital, Platte Valley Hospital

Front Range
Western Slope
Unknown

Which area in Montana?
Billings: St. Vincent
General: St. James, Holy Rosary

General
Billings
Unknown

County

Organization Name

Please explain what type of organization:

Anyone in the community can request gun locks.
Intermountain Health is gathering information to see if any of the following groups are receiving gun locks, please select the group that best describes those who will receive them from your order. If none of the groups below, please select "None of the above".

Individuals recently released from treatment and incarceration
Uninsured or underinsured individuals, patients and employees at local CHCs and FQHCs
Individuals employed in construction, extraction (e.g., mining and petroleum drilling), food preparation, hospitality and serving within rural as well as metro areas
School and University students, employees, parents
Faith communities and those they serve
Public sector employees including townships, city, and county workers
Internal IH departments
None of the above (please describe)

Quantity of Kits
Each gun lock order will be made in 25 lock quantities, accompanied by educational brochures. Talking points and signage can be downloaded from the links on this page. Every effort will be made to fulfill requests as supply permits. If we are unable to fill a request when submitted, we will make every effort to fill it as soon as new supply becomes available. Brochures are double sided, folded pamphlets that are intended to be stapled around each individual gun lock. The gun locks and brochures will not come pre-stabled and must be put together (“kitted”) by ordering organization or entity. Please click here to view gun lock kitting instructions if needed. It works best to have a conversation if possible and explain that off-site storage is the safest when possible and if not possible then these on-site storage guidelines are next best.

How many kits? (must be in multiples of 25, i.e. 25, 50, 75, 100, etc.)

Language of Gunlocks
Gunlocks can be ordered with accompanying information in English or Spanish.

How many in English? (must be in multiples of 25, i.e. 25, 50, 75, 100, etc.)

Facility Address

Name of person/department who will be receiving gunlocks

Street

City

Zipcode

Agreement
Gun locks are intended to be provided to the public free of charge.  By requesting and accepting the gun locks and brochures that accompany them I / my organization agree to:

Provide them free of charge to any person requesting them

I agree

Ensure that each gun lock given out includes the educational brochure

I agree

Click here to download When Firearm Safety and Safe Storage is Your Goal printable PDF.