Narcan Training Application and Post-Survey (Website)

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* 1. Trainee Application Information

First Name

Last Name

Date of Birth

Age

Address

Address 2

City/Town

State/Province

Zip/Postal Code

Email Address

Phone Number

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* 2. Sex (Optional)

Male

Female

Not stated

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* 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

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* 4. I hereby certify that the information contained in this application is complete and accurate to the best of my knowledge.

Electronic Signature

Date

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* 5. Please check which category best describes your reason to receive Narcan training.

Occupation

Volunteer work

Family member

Social experience

Law enforcement training

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* 6. Organization

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* 7. Narcan is only effective in reversing opioid overdoses.

True

False

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* 8. The Narcan kit you will be dispensed contains 2 doses of Narcan.

True

False

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* 9. Rate your confidence in your ability to administer Narcan.

1 - No confidence

2 - Low level of confidence

3 - Average level of confidence

4 - Moderately high level of confidence

5 - High level of confidence

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* 10. Rate your knowledge of the proper use and storage of Narcan.

1 - No knowledge

2 - Low level of knowledge

3 - Average level of knowledge

4 - Moderately high level of knowledge

5 - High level of knowledge

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* 11. I feel prepared to respond to an overdose.

True

False

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* 12. I am likely to use Narcan when responding to an overdose.

1 - Not likely

2 - Somewhat likely

3 - Unsure

4 - Moderately likely

5 - Very likely

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* 13. I am likely to share Narcan training and other resources with survivors and near misses.

1 - Not likely

2 - Somewhat likely

3 - Unsure

4 - Moderately likely

5 - Very likely

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* 14. Would you like to obtain a free Narcan kit?

Yes

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* 15. Would you like to obtain a Narcan Training Certificate of Completion?

Yes