Narcan Use Survey

Please answer 6 questions to ANONYMOUSLY report using Narcan provided through the Narcan Leave Behind Program. 

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* 1. What is today's date?

Date

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* 2. What was the approximate date & time the Narcan was used?

Date
Time

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* 3. How many doses of Narcan were used?  Each box contains 2 doses.

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* 4. Was 9-1-1 called?

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* 5. Did the individual survive?

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* 6. Where did you receive your Narcan Leave Behind Kit?

T