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Narcan Reporting Survey
Narcan Use Survey
Please answer 6 questions to ANONYMOUSLY report using Narcan provided through the Narcan Leave Behind Program.
*
1.
What is today's date?
(Required.)
Date / Time
Date
January
February
March
April
May
June
July
August
September
October
November
December
1900
1901
1902
1903
1904
1905
1906
1907
1908
1909
1910
1911
1912
1913
1914
1915
1916
Su
Sunday
Mo
Monday
Tu
Tuesday
We
Wednesday
Th
Thursday
Fr
Friday
Sa
Saturday
01
02
03
04
05
06
07
08
09
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
2.
What was the approximate date & time the Narcan was used?
Date / Time
Date
January
February
March
April
May
June
July
August
September
October
November
December
1900
1901
1902
1903
1904
1905
1906
1907
1908
1909
1910
1911
1912
1913
1914
1915
1916
Su
Sunday
Mo
Monday
Tu
Tuesday
We
Wednesday
Th
Thursday
Fr
Friday
Sa
Saturday
01
02
03
04
05
06
07
08
09
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Hour
Time
:
Minutes
AM/PM
-
AM
PM
*
3.
How many doses of Narcan were used? Each box contains 2 doses.
(Required.)
1
2
More than 2
Don't know
*
4.
Was 9-1-1 called?
(Required.)
Yes
No
Don't know
*
5.
Did the individual survive?
(Required.)
Yes
No
Don't know
*
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)