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* 1. In what county did you receive your naloxone?

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* 2. Today's date

Date

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* 3. Enter your unique ID CODE
This should match the code you created when you got your naloxone. ID Codes are only used to link data for analysis.They cannot and are not used for any other purpose.

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* 4. Since you received your naloxone kit about 30 days ago, have you. . .

  Yes No Not sure
Told someone what can cause an overdose
Told someone how to get naloxone
Told someone about the Good Samaritan Overdose law
Told someone you had naloxone
Told someone where you keep your naloxone
Taught someone what to do in an overdose
Taught someone how to use naloxone
Witnessed an opioid overdose

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* 5. What has happened with the two doses of naloxone you received from us? (Dose 1 of 2)

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* 6. What has happened with the two doses of naloxone you received from us? (Dose 2 of 2)

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* 7. Why did you get this naloxone kit? (check all that apply)

T