1.3. Email *
1.4. Phone *
1.8. County of training * Adams Allen Bartholomew Benton Blackford Boone Brown Carroll Cass Clark Clay Clinton Crawford Daviess Dearborn Decatur De Kalb Delaware Dubois Elkhart Fayette Floyd Fountain Franklin Fulton Gibson Grant Greene Hamilton Hancock Harrison Hendricks Henry Howard Huntington Jackson Jasper Jay Jefferson Jennings Johnson Knox Kosciusko La Porte Lagrange Lake Lawrence Madison Marion Marshall Martin Miami Monroe Montgomery Morgan Newton Noble Ohio Orange Owen Parke Perry Pike Porter Posey Pulaski Putnam Randolph Ripley Rush St. Joseph Scott Shelby Spencer Starke Steuben Sullivan Switzerland Tippecanoe Tipton Union Vanderburgh Vermillion Vigo Wabash Warren Warrick Washington Wayne Wells White Whitley
1.9. County of residence * Adams Allen Bartholomew Benton Blackford Boone Brown Carroll Cass Clark Clay Clinton Crawford Daviess Dearborn Decatur De Kalb Delaware Dubois Elkhart Fayette Floyd Fountain Franklin Fulton Gibson Grant Greene Hamilton Hancock Harrison Hendricks Henry Howard Huntington Jackson Jasper Jay Jefferson Jennings Johnson Knox Kosciusko La Porte Lagrange Lake Lawrence Madison Marion Marshall Martin Miami Monroe Montgomery Morgan Newton Noble Ohio Orange Owen Parke Perry Pike Porter Posey Pulaski Putnam Randolph Ripley Rush St. Joseph Scott Shelby Spencer Starke Steuben Sullivan Switzerland Tippecanoe Tipton Union Vanderburgh Vermillion Vigo Wabash Warren Warrick Washington Wayne Wells White Whitley
1.10. Please indicate the number of Narcan kits you would like to receive: *
1.11. Other:
1.12. Other:
1.14. Individual/Organization from which you obtained your training:
1.15. Other:
1.16. What is your age? *
1.19. Other:
2.5. County of residence * Adams Allen Bartholomew Benton Blackford Boone Brown Carroll Cass Clark Clay Clinton Crawford Daviess Dearborn Decatur De Kalb Delaware Dubois Elkhart Fayette Floyd Fountain Franklin Fulton Gibson Grant Greene Hamilton Hancock Harrison Hendricks Henry Howard Huntington Jackson Jasper Jay Jefferson Jennings Johnson Knox Kosciusko La Porte Lagrange Lake Lawrence Madison Marion Marshall Martin Miami Monroe Montgomery Morgan Newton Noble Ohio Orange Owen Parke Perry Pike Porter Posey Pulaski Putnam Randolph Ripley Rush St. Joseph Scott Shelby Spencer Starke Steuben Sullivan Switzerland Tippecanoe Tipton Union Vanderburgh Vermillion Vigo Wabash Warren Warrick Washington Wayne Wells White Whitley
2.9. If expired, how many?
2.11. If yes, please indicate how many kits were returned:
2.12. How many Narcan kits were lost?
2.13. Describe the circumstances of each Narcan kit that was lost (e.g. stolen, taken by police, misplaced, etc):
2.14. Dates of loss:
2.16. Since you participated in the overdose training or since your last follow-up, how many kits have you redistributed to others?
2.17. Who did you redistribute to? Other:
2.18. Date of redistribution:
2.19. Other:
2.20. County/city Narcan(s) was redistributed to (please list all):
2.21. In the time since you participated in the overdose response training or since your last refill, how many overdoses have you witnessed?
2.22. Of those overdoses you have witnessed, how many resulted in Narcan being used?
2.23. Of those overdoses you have witnessed, how many times was 911 called?
2.24. Describe the general circumstances of each witnessed overdose:
2.25. Date(s) of overdose:
2.26. County/city Narcan was used in:
2.27. Other:
2.28. What was the gender of the person who overdosed?
2.29. What was their approximate age?
2.30. Other:
2.31. Other:
2.32. Other:
2.33. If you DID give naloxone/Narcan, how many doses did you give?
2.35. Did you have any trouble putting together the Narcan or using it? (please specify)
2.36. Other:
2.37. Other:
2.27.a. Other
2.28.a. What was the gender of the person who overdosed?
2.29.a. What was their approximate age?
2.30.a. Other:
2.31.a. What setting did it occur in? (Other)
2.32.a. Other:
2.33.a. If you DID give naloxone/Narcan, how many doses did you give?
2.35.a. Did you have any trouble putting together the Narcan or using it? (please specify)
2.37.a. Other:
2.37.a. Other:
2.27.b. Other:
2.28.b. What was the gender of the person who overdosed?
2.29.b. What was their approximate age?
2.30.b. Other:
2.31.b. Other:
2.32.b. Other:
2.33.b. If you DID give naloxone/Narcan, how many doses did you give?
2.35.b. Did you have any trouble putting together the Narcan or using it? (please specify)
2.37.b. Other:
2.37.b. Other:
3.3. Email *
3.4. Phone *
3.6. Company/Department/Agency Name
3.8. Additional Comments Regarding County Coverage
3.9. Requested number of kits *
3.10. Other
3.11. Describe in detail your plans for naloxone use *
3.12. In the space below provide a description of the heroin and opioid overdose problem in your community. *
4.2. Name of organization/agency: *
4.3. Other:
4.4. County of service * Adams Allen Bartholomew Benton Blackford Boone Brown Carroll Cass Clark Clay Clinton Crawford Daviess Dearborn Decatur De Kalb Delaware Dubois Elkhart Fayette Floyd Fountain Franklin Fulton Gibson Grant Greene Hamilton Hancock Harrison Hendricks Henry Howard Huntington Jackson Jasper Jay Jefferson Jennings Johnson Knox Kosciusko La Porte Lagrange Lake Lawrence Madison Marion Marshall Martin Miami Monroe Montgomery Morgan Newton Noble Ohio Orange Owen Parke Perry Pike Porter Posey Pulaski Putnam Randolph Ripley Rush St. Joseph Scott Shelby Spencer Starke Steuben Sullivan Switzerland Tippecanoe Tipton Union Vanderburgh Vermillion Vigo Wabash Warren Warrick Washington Wayne Wells White Whitley
4.5. Lot#
4.6. Other:
4.9. Other:
4.10. Other:
4.11. Other:
4.12. If you DID give naloxone/Narcan, how many doses did you give?
4.14. Did you have any trouble putting together the Narcan or using it? (please specify)
4.15. Other:
4.16. Other:
