Narcan Reporting Survey

Narcan Use Survey

Please answer 6 questions to ANONYMOUSLY report using Narcan provided through the Narcan Leave Behind Program.

Question Title

1. What is today's date? (Required.)

Date / Time

Date

Question Title

2. What was the approximate date & time the Narcan was used?

Date / Time

Date

Time

AM/PM

Question Title

3. How many doses of Narcan were used? Each box contains 2 doses. (Required.)

More than 2

Don't know

Question Title

4. Was 9-1-1 called? (Required.)

Yes

Don't know

Question Title

5. Did the individual survive? (Required.)

Yes

Don't know

Question Title

6. Where did you receive your Narcan Leave Behind Kit? (Required.)

Minot Fire Department

Minot Rural Fire Department

First District Health Unit

Other (please specify)

Narcan Reporting Survey

Narcan Use Survey

Question Title

* 1. What is today's date? (Required.)

Question Title

* 2. What was the approximate date & time the Narcan was used?

Question Title

* 3. How many doses of Narcan were used? Each box contains 2 doses. (Required.)

Question Title

* 4. Was 9-1-1 called? (Required.)

Question Title

* 5. Did the individual survive? (Required.)

Question Title

* 6. Where did you receive your Narcan Leave Behind Kit? (Required.)

1. What is today's date? (Required.)

2. What was the approximate date & time the Narcan was used?

3. How many doses of Narcan were used? Each box contains 2 doses. (Required.)

4. Was 9-1-1 called? (Required.)

5. Did the individual survive? (Required.)

6. Where did you receive your Narcan Leave Behind Kit? (Required.)