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2. Thank You for watching the Narcan training video!

   Through its Opioid Overdose Prevention Program, Steuben County Public Health is able to offer a free Narcan kit to residents who complete the online training video and submit the form below.

6. To receive your FREE NARCAN KIT, please enter your name and mailing address.

   Your information is strictly confidential and will not be shared with third parties.

8. First Name*
9. Last Name*
11. Address*
13. City*
14. State*
15. Zip Code*
17. Email Address

    Enter your email address to receive periodic information about local addiction and recovery resources. Your information will not be shared with third parties.

18. Date of Birth
22. Check the box(es) below for any resources you would like to receive.

    1. I would like to receive confidential peer support. Peers engage and connect individuals to local services by utilizing their recovery expertise, professional training and living experience.
    2. I would like to receive a list of local resources available regarding substance use.
24. Tell us about your MOTIVATION to take this training. Why did you wish to learn more about Narcan?*

    (multiple answers possible)

    1. I am concerned about somebody I know overdosing on opioids, such as a family member, friend, or colleague.
    2. I am concerned about myself overdosing on opioids.
    3. My job requires me to take an opioid overdose prevention / Narcan training.
    4. I want to have the knowledge and skills to be able to intervene effectively in an opioid overdose emergency.
25. Have you ever witnessed an overdose?*

    (multiple answers possible)

    1. I have witnessed an overdose that resulted in a fatality; no Narcan was administered at the scene.
    2. I have witnessed an overdose that resulted in a fatality; Narcan was administered at the scene.
    3. I have witnessed an overdose that resulted in a successful rescue; no Narcan was administered at the scene.
    4. I have witnessed an overdose that resulted in a successful rescue; Narcan was administered at the scene.
    5. I have never witnessed an overdose.
29. Tell us about YOURSELF.

    Your information will not be shared with third parties and will be used for statistical purposes only.

31. What is your gender?*

    1. Female
    2. Male
    3. Transgender
    4. Other
32. How would you describe yourself?*

    1. White or Caucasian
    2. Black or African American
    3. Hispanic or Latino
    4. American Indian or Alaska Native
    5. Asian
    6. Native Hawaiian or Other Pacific Islander
    7. Middle Eastern or North African
    8. Other
34. Which choice below best describes where you work?*

    1. Community Center/Library
    2. Emergency Services (EMT, Paramedic, Firefighter)
    3. Hospital/Urgent Care
    4. Jail/Prison/Law enforcement
    5. Nightlife Establishment (Bar, Club)
    6. School/Educational setting
    7. Social Services
    8. Other
36. If "Other", please specify where you work.
40. How did you hear about this online training?*

    (multiple answers possible)

    1. Through word of mouth (friend, family member)
    2. I read about it (news article, social media)
    3. It was recommended by my workplace
    4. At a Narcan distribution event in the community
    5. It was recommended by a first responder or law enforcement officer
    6. I saw a flyer at a local establishment
    7. I received a flyer in the mail
    8. It was recommended by a healthcare or other service provider
    9. Outreach
42. In need of replacement Narcan?

    1. Check this box if you need replacement Narcan due to it being used or expired.

    * If you used the Narcan, please call (607) 664-2438 for anonymous reporting.

46. Post-Training Survey Responses

    Please evaluate the following survey responses using a scale of 1 - 5, with 1 being "Not at all confident" and 5 being "Very Confident".

48. I can manage an overdose situation.

    1. 1
    2. 2
    3. 3
    4. 4
    5. 5
49. I can recognize the symptoms of an opioid overdose.

    1. 1
    2. 2
    3. 3
    4. 4
    5. 5
50. I can recognize the risk factors that increase the possibility of an overdose.

    1. 1
    2. 2
    3. 3
    4. 4
    5. 5
52. I can administer Narcan/Naloxone.

    1. 1
    2. 2
    3. 3
    4. 4
    5. 5
53. I can perform basic life support and follow-up care after administering Narcan.

    1. 1
    2. 2
    3. 3
    4. 4
    5. 5

55. Please evaluate the following survey responses using a scale of 1 - 5, with 1 being "Strongly Disagree" and 5 being "Strongly Agree".

57. The material was presented in a way that was easy to understand.

    1. 1
    2. 2
    3. 3
    4. 4
    5. 5
58. I learned new information or skills as a result of my participation in this training.

    1. 1
    2. 2
    3. 3
    4. 4
    5. 5
62. Thank you for your time and willingness to learn about Narcan!

    Be on the lookout for your free Narcan kit in the mail.

Leave This Blank:


64. 1. Receive an email copy of this form.
65. Email address

    This field is not part of the form submission.

66. Submit

* indicates a required field