We are working to follow public health guidelines surrounding the outbreak of the novel coronavirus. To reduce the amount of interaction trainers have with the public we are only requiring the number of people that you are training/dispensing naloxone to until further notice. This form is to be completed only by the REVIVE! Trainer providing education. We ask that weekly you provide the information for trainings that are being conducted. 

If you have any questions please contact Alexandria Robinson, REVIVE! Coordinator at alexandria.robinson@dbhds.virginia.gov.

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* 1. What is your First and Last Name

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* 2. What agency do you work for? If not with an agency please enter "Public Member".

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* 3. How many people did you TRAIN how to administer naloxone? (number values only)

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* 4. How many of these people did you DISPENSE naloxone to? (number values only)

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