*1.I Certify that I have watched the Project Dawn training video on Narcan and verbalize understanding the indications and usage for Narcan.(Required.)

Yes

No

2.What is your age range?

Under 18

18-24

25-34

35-44

45-54

55-64

65+

Prefer not to say

3.What race(s) and ethnicity do you consider yourself? Check all that apply.

American Indian or Alaska Native

Asian or Asian American

Black or African American

Hispanic or Latino

Middle Eastern or North African

Native Hawaiian or other Pacific Islander

White

Another race

Prefer not to say

4.In which Ohio zip code do you live?

5.In which Oho county do you live?

6.Have you used drugs other than marijuana in the last year?

Yes

No

Prefer not to say

7.Have you ever overdosed or witnessed an overdose?

Yes

No

Prefer not to say

8.Is this the first Narcan kit you have received?

Yes

No

Prefer not to say

9.If No to question seven, what happened to your Narcan?

Expired

Prefer not to say

Used on someone or yourself?

Other (please specify)

10.If Narcan was used on someone, did the person survive?

Yes

No

Prefer not to say

*11.Where is the Narcan kit being sent to?(Required.)

Name *

Address *

Address 2

City/Town *

State/Province *

ZIP/Postal Code *

Country