NaloxBox Collaborator Survey

Thank you for being a NaloxBox Collaborator! You have made an important step in ensuring naloxone is more accessible when needed.

In order to improve our products, your projects, and our outcomes, we ask that you share this short survey (designed to take just 1 minute) with additional partners and answer each question to the best of your ability.

The information obtained in this survey will be used to determine success, formulate  geographic maps of NaloxBox locations, and spread awareness of public access naloxone and overdose-reversal tools in your area.

All information collected will be used for data purposes only. No personal information will be disclosed.

We need your help as a NaloxBox collaborator, so let’s  collaborate!

Question Title

* 1. Where is your NaloxBox located?

City:

State:

Address:

Company:

Building:

Floor/Room Number:

Question Title

* 2. Have you replaced the original naloxone kit stored in your NaloxBox?
If yes, (please explain your reasoning)

Expired

Stolen

Damaged/tampered

Used in response to a suspected overdose

I have not replaced the original naloxone kit

Other (please specify)

Question Title

* 3. What form of naloxone is stored in your NaloxBox?

Intranasal (Narcan)

Intramuscular naloxone (vial)

Auto injector (Evzio)

Other (please specify)

Question Title

* 4. How do you furnish naloxone for your NaloxBox?

Purchased a kit at a Pharmacy under my state's Collaboartive Practice Agreement

Contacted a local overdose prevention and naloxone program

Utilized my local or state level health department's overdose prevention or injury prevention program for resources

Other (please specify)

Question Title

* 5. Which of the following tools in your NaloxBox have been used in response to a suspected overdose? (please check all that apply)

CPR Barrier Device

Intranasal/Intramuscular Instruction Booklet

Naloxone Kit

None of the overdose response tools have been used

Question Title

* 6. To your knowledge, how many opioid overdoses have been reversed using the response tools in your NaloxBox?

Question Title

* 7. Have any of the contents in your NaloxBox been tampered with at your facility?

Yes

If yes, (please specify)

Question Title

* 8. The feedback you received about the NaloxBox at your facility has been, on average:

Very positive

Positive

Neutral

Negative

Very negative

I have not received any feedback.

Question Title

* 9. Where are some places you'd like to see new NaloxBox units installed?

Question Title

* 10. What feedback or suggestions do you have about NaloxBox?

If you own more than one NaloxBox, please provide us with the location of each site!
For more information contact us at info@naloxbox.org

NaloxBox Collaborator Survey

Question Title

* 1. Where is your NaloxBox located?

Question Title

* 2. Have you replaced the original naloxone kit stored in your NaloxBox? If yes, (please explain your reasoning)

Question Title

* 3. What form of naloxone is stored in your NaloxBox?

Question Title

* 4. How do you furnish naloxone for your NaloxBox?

Question Title

* 5. Which of the following tools in your NaloxBox have been used in response to a suspected overdose? (please check all that apply)

Question Title

* 6. To your knowledge, how many opioid overdoses have been reversed using the response tools in your NaloxBox?

Question Title

* 7. Have any of the contents in your NaloxBox been tampered with at your facility?

Question Title

* 8. The feedback you received about the NaloxBox at your facility has been, on average:

Question Title

* 9. Where are some places you'd like to see new NaloxBox units installed?

Question Title

* 10. What feedback or suggestions do you have about NaloxBox?

* 2. Have you replaced the original naloxone kit stored in your NaloxBox?
If yes, (please explain your reasoning)