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Use Naloxone to save a life
Use Naloxone to save a life
1.
Do you live in Ohio
Yes
No
what is your first and last name and your address?
2.
I watched the video provided on the website
Yes
No
*
3.
What is your age?
(Required.)
Under 18
18-24
25-34
35-44
45-54
55-64
65+
4.
Which race/ethnicity best describes you?
American Indian or Alaskan Native
Asian / Pacific Islander
Black or African American
Hispanic
White / Caucasian
Other
prefer not to say
Multiple ethnicity / Other (please specify)
5.
What is your gender?
Female
Male
prefer not to say
6.
How helpful was the content presented at the event?
Extremely helpful
Very helpful
Somewhat helpful
Not so helpful
Not at all helpful
7.
Would you like to receive additional information about Naloxone? Please provide your contact info below.
Phone call
Text
Email
No thank you.
Include phone number or email address
8.
Is this the first naloxone (Narcan) kit you have received?
Yes
No
9.
If no, what happened to the first kit?
The kit was used on another person who was over dosing and they survived
The kit was used on another person who was over dosing and they did not survive
The kit was used on me.
The medication kit expired
other
10.
What is the intended use for naloxone?
If I overdose
If a friend or family member overdoses
If I see someone overdose