Please complete the evaluation for today’s training session-your feedback is valuable to us and appreciated. Indicate how much you agree or disagree to the following statements by filling in the circle that reflects your answer.

*1.Please provide the following information:(Required.)

Date of presentation:

Title of presentation:

*2.Which county do you represent?(Required.)

AllenAndersonAtchisonBarberBartonBourbonBrownButlerChaseChautauquaCherokeeCheyenneClarkClayCloudCoffeyComancheCowleyCrawfordDecaturDickinsonDoniphanDouglasEdwardsElkEllisEllsworthFinneyFordFranklinGearyGoveGrahamGrantGrayGreelyGreenwoodHamiltonHarperHarveyHaskellHodgemanJacksonJeffersonJewellJohnsonKearnyKingmanKiowaLabetteLaneLeavenworthLincolnLinnLoganLyonMarionMarshallMcPhersonMeadeMiamiMitchellMontgomeryMorrisMortonNemahaNeoshoNessNortonOsageOsborneOttawaPawneePhillipsPottawatomiePrattRawlinsRenoRepublicRiceRileyRooksRushRussellSalineScottSedgwickSewardShawneeSheridanShermanSmithStaffordStantonStevensSumnerThomasTregoWabaunseeWallaceWashingtonWichitaWilsonWoodsonWyandotte

3.After attending this training, how confident are you that you can do the following?

Very Confident

Moderately Confident

Neutral

Slightly Confident

Not at All Confident

Increased knowledge and awareness related to prescription drug and opioid misuse.

Very Confident

Moderately Confident

Neutral

Slightly Confident

Not at All Confident

Find resources (disposal sites, naloxone, etc.) related to opioids.

Very Confident

Moderately Confident

Neutral

Slightly Confident

Not at All Confident

Identify resources to connect patients with treatment resources.

Very Confident

Moderately Confident

Neutral

Slightly Confident

Not at All Confident

Recognize an opioid overdose.

Very Confident

Moderately Confident

Neutral

Slightly Confident

Not at All Confident

Safely use, store, and dispose prescription drugs.

Very Confident

Moderately Confident

Neutral

Slightly Confident

Not at All Confident

Administer Naloxone.

Very Confident

Moderately Confident

Neutral

Slightly Confident

Not at All Confident

4.I feel confident I can administer Naloxone.

Yes

No

5.I am informed and have the skills and knowledge to respond if needed.

Yes

No

6.Is there any additional information you would like to gain following this training?

7.Please provide additional feedback and comments below: