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Narcan Training Application and Post-Survey (Website)
*
1.
Trainee Application Information
(Required.)
First Name
Last Name
Date of Birth
Age
Address
Address 2
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,
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