Application Form for Becoming a Community Access NARCAN® Site

Instructions: Please complete and submit the form below to apply to become a "Community Access NARCAN® Site" and receive a NARCAN® Emergency Cabinet.

NARCAN® Emergency Cabinets are secure metal units (very similar to publicly sited AED machines), which each contain two doses of NARCAN® nasal spray, along with instructions for its use. When appropriately deployed in specific locations with high rates of opioid overdose, the units are intended to increase access to naloxone during the time of a life-threatening emergency.

Question Title

* 1. Site Name:

Question Title

* 2. Address:

Question Title

* 3. City/Town:

Question Title

* 4. ZIP/Postal Code:

Question Title

* 5. Hours of Operation:

Question Title

* 6. Type of Establishment:

Question Title

* 7. Website Address:

Question Title

* 8. Contact First Name:

Question Title

* 9. Contact Last Name:

Question Title

* 10. Contact Phone Number:

Question Title

* 11. Contact Email:

Question Title

* 12. Number of Cabinets Requested:

Question Title

* 13. Confirmation

By submitting this form, I confirm that I am an authorized representative of the establishment listed above, and that the site personnel agree to keep a limited supply of NARCAN®/naloxone on the premises, collect necessary paperwork, and to refer interested individuals to comprehensive community trainings as schedule permits. I also understand that my site will be listed on the public access listing on the Oneida County Opioid Task Force website and Overdose Response Team Dashboard.

Question Title

* 14. Authorized Representative Signature: