Leave Behind Narcan

WHAT IS YOUR UNIT IDENTIFIER?

GENDER OF PERSON RECEIVING LEAVE-BEHIND NARCAN KIT or PERSON WHO A DOSE OF NARCAN WAS ADMINISTERED TO. (required)

Female

Male

Other

WHAT IS/ARE THE NUMBER(S) ON THE LABEL AT THE TOP OF THE LEAVE-BEHIND NARCAN KIT(S)? (required)

HOW MANY BOXES WERE GIVEN? (required)

1

2

WAS THE NARCAN GIVEN TO A PATIENT OR A BYSTANDER?

If OTHER

WOULD THE PATIENT/PERSON LIKE SOME ONE TO FOLLOW UP AND PROVIDE ADDICTION TREATMENT AND RESOURCES? (required)

YES

NO

CONTACT INFORMATION FOR FOLLOW UP

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