2. THANK YOU for watching the Narcan training video!

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

4. 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.
6. First Name*
7. Last Name*
9. Address*
11. City*
12. State*
13. Zip Code*
15. Email Address (optional)
    Enter your email address to receive periodic information about local addiction and recovery resources. Your information will not be shared with third parties.
17. Please check the box if you would like to be contacted by a recovery peer advocate.

    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 lived experience.

18. Your contact information
    Please indicate how you would like to be contacted by a peer (phone number, email).
20. 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.”
21. 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.
23. Tell us about YOURSELF. What is your gender?*

    1. Female
    2. Male
    3. Transgender
    4. Other

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

    
    

24. 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
25. What is your age?*
27. Are you a first responder?*

    1. Yes, Law Enforcement
    2. Yes, EMT/Paramedic
    3. Yes, Firefighter
    4. No
28. Do you work with people in the areas of mental health, addiction, or recovery?*

    1. Yes
    2. No
29. Please specify your occupation*
31. How did you hear about this online training?*

    More than one answer can be selected:

    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
33. 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:


35. 1. Receive an email copy of this form.
36. Email address

    This field is not part of the form submission.

37. Submit Submit and Print

* indicates a required field