Report Narcan Use and Request New Narcan Kit

2. 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.

   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.

4. 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.

   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. 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.

    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.

19. Did you use Narcan to revive someone who you thought had overdosed?*

    1. Yes
    2. No

20. Who did you use Narcan on?*

    1. Spouse/Partner
    2. Parent
    3. Child
    4. Other family member
    5. Friend
    6. Co-worker
    7. Stranger
    8. Other

21. What was the patient's gender?*

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

22. What is the patient's race/ethnicity?*

    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

24. Where did you get the Narcan from?*

    1. This website
    2. Pharmacy
    3. Healthcare or other Service Provider
    4. Hospital
    5. Family member or Friend
    6. Syringe Exchange

25. Did anyone bring the patient to the emergency room?*

    1. Yes
    2. No
    3. I don't know

26. Did anyone call 911?*

    1. Yes
    2. No
    3. I don't know

27. Did the patient survive the overdose?*

    1. Yes
    2. No
    3. I don't know

29. When did the overdose happen (month/year)?*

30. Where did the overdose happen (city/town/village)? *

31. At what location did the overdose happen?*

    1. Your residence
    2. Someone else's residence
    3. Public place (store, restaurant, park, etc.)
    4. Vehicle
    5. Hotel, motel, shelter
    6. Other

33. Thank you for responding to an overdose emergency!
    Be on the lookout for your free Narcan kit in the mail.

    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

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