Skip to content
Check Screen Reader Mode to make this survey compatible with screen readers.
Check Screen Reader Mode to make this survey compatible with screen readers.
Narcan Training Application and Post-Survey (Website)
*
1.
Trainee Application Information
(Required.)
First Name
Last Name
Date of Birth
Age
Address
City/Town
State/Province
Zip/Postal Code
Email Address
Phone Number
2.
Sex (Optional)
Male
Female
Not stated
3.
Race/Ethnicity (check all that apply)
White or Caucasian
Black or African American
American Indian or Alaska Native
Native Hawaiian or other Pacific Islander
Asian or Asian American
Hispanic or Latino
*
4.
I hereby certify that the information contained in this application is complete and accurate to the best of my knowledge.
(Required.)
Electronic Signature
Date
*
5.
Please check which category best describes your reason to receive Narcan training.
(Required.)
Occupation
Volunteer work
Family member
Social experience
Law enforcement training
*
6.
Organization
(Required.)
*
7.
Narcan is only effective in reversing opioid overdoses.
(Required.)
True
False
*
8.
The Narcan kit you will be dispensed contains 2 doses of Narcan.
(Required.)
True
False
*
9.
Rate your confidence in your ability to administer Narcan.
(Required.)
1 - No confidence
2 - Low level of confidence
3 - Average level of confidence
4 - Moderately high level of confidence
5 - High level of confidence
*
10.
Rate your knowledge of the proper use and storage of Narcan.
(Required.)
1 - No knowledge
2 - Low level of knowledge
3 - Average level of knowledge
4 - Moderately high level of knowledge
5 - High level of knowledge
*
11.
I feel prepared to respond to an overdose.
(Required.)
True
False
*
12.
I am likely to use Narcan when responding to an overdose.
(Required.)
1 - Not likely
2 - Somewhat likely
3 - Unsure
4 - Moderately likely
5 - Very likely
*
13.
I am likely to share Narcan training and other resources with survivors and near misses.
(Required.)
1 - Not likely
2 - Somewhat likely
3 - Unsure
4 - Moderately likely
5 - Very likely
*
14.
Would you like to obtain a free Narcan kit?
(Required.)
Yes
No
15.
Would you like to obtain a Narcan Training Certificate of Completion?
Yes
No
Current Progress,
0 of 15 answered
