By signing in or creating an account, some fields will auto-populate with your information and your submitted forms will be saved and accessible to you.

Report Narcan Use and Request New Narcan Kit

  1. THANK YOU for carrying and administering Narcan during an opioid overdose emergency!
    You have taken a crucial step in helping to save someone's life. As part of the HEALing Communities Study, Cayuga County is able to offer a free replenishment Narcan kit to adult county residents who administered Narcan and submit the form below. Training and Narcan are provided by the Cayuga County Community Mental Health Center, a registered opioid overdose prevention program.
  2. To receive a replenishment FREE NARCAN KIT, please enter your name and mailing address.
    Your information is strictly confidential and will not be shared with third parties.
  3. Enter your email address to receive periodic information about local addiction and recovery resources. Your information will not be shared with third parties.

  4. Please check the box if you would like to be contacted by a recovery peer advocate.
    Peers engage and connect individuals to local services by utilizing their recovery expertise, professional training, and lived experience.
  5. Tell us about the OVERDOSE EMERGENCY you attended
    This information will not be shared with third parties and will be used for statistical purposes only. It will help us better understand the circumstances during which Narcan was used and aid our prevention efforts.
  6. Please indicate how you would like to be contacted by a peer (phone number, email).
  7. Did you use Narcan to revive someone who you thought had overdosed?*
  8. Who did you use Narcan on?*
  9. What was the patient's gender?*
  10. What is the patient's race/ethnicity?*
  11. Where did you get the Narcan from?*
  12. Did anyone bring the patient to the emergency room?*
  13. Did anyone call 911?*
  14. Did the patient survive the overdose?*
  15. At what location did the overdose happen?*
  16. Thank you for responding to an overdose emergency!
    Be on the lookout for your free Narcan kit in the mail.
  17. Leave This Blank:

  18. This field is not part of the form submission.