REVIVE Trainer's Report of Training

Thank you for providing REVIVE! Training. Please fill in the requested information below, regarding your training. To ensure accuracy of data reports, please submit a form for each training provided.

If you have any questions please contact the REVIVE! Team at revive@dbhds.virginia.gov.

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* 1. Trainer's First and Last Name

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* 2. Organization providing Training/ Trainer's Agency:

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* 3. Date of Training

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* 4. City of Training (PLEASE PUT THE CITY ONLY)

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* 5. Zip Code of Training (PLEASE LIST THE ZIP CODE ONLY):

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* 6. Type of Training

Lay Rescuer

Rapid REVIVE!

Training of Trainers

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* 7. How many individuals did you train during this session?

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* 8. Was Naloxone dispensed during this training? (If being dispensed at a later date, please check "yes").

Yes

No

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* 9. Is so, how many Naloxone kits were dispensed? (If being dispensed at a later date, please put the number. Please type n/a if Naloxone was not dispensed. Please either put a number or N/A. PLEASE DO NOT PROVIDE AN EXPLANATION)

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* 10. Were REVIVE! Kits distributed during this training? (If being dispensed at a later date, please check "yes").

Yes

No

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* 11. If so, how many? (Please type n/a if REVIVE! Kits were not distributed. If being dispensed at a later date, please put the number. Please only type n/a if Naloxone was not dispensed. Please either put a number or N/A ONLY. PLEASE DO NOT PROVIDE AN EXPLANATION.)