Back to School Availability of Prescribed Epinephrine

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* 1. Have you been unable to fill or refill a prescription for epinephrine auto injectors in the last three months due to a lack of adequate supply at your pharmacy?

I could not fill it at all

I could fill it, but only partially

I was able to fill it completely

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* 2. Which device(s) were you trying to obtain?

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* 3. If you could not fill your prescription, were you able to obtain an alternate brand, and if so, which one?

Yes

No

If yes, specify below.

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* 4. What is the expiration date of the epinephrine auto injectors you obtained? (Check multiple boxes if you obtained more than one set of EAIs)

Less than six months from date of purchase

Between six months and one year from date of purchase

More than one year from date of purchase

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* 5. At what pharmacy were you able to complete your purchase?

Other (please specify)

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* 6. In what state is the pharmacy located?

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* 7. Comments?

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* 8. OPTIONAL: Name of person completing the survey

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* 9. OPTIONAL: Your email address