JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.
Naloxone (Narcan) Usage
Sign in to Google
to save your progress.
Learn more
The information in this form is collected anonymously. You are asked to voluntarily provide this information which will be aggregated for our reporting to the State of Florida to keep this medication free. Thank you.
Did you obtain Naloxone (Narcan) from The Blue Plaid Society?
Yes
No
Clear selection
Did you use Naloxone (Narcan) to reverse the affects of a suspected opioid poisoning or overdose?
Yes
No
Clear selection
If you answered Yes above, How many kits (1 spray per kit) did you use?
Choose
1
2
3
4
5
Please provide any comments, stories, or anything you would like us to know. Any information provided is confidential and will not be shared outside of The Blue Plaid Society organization. (Optional).
Your answer
If you want to be contacted, please provide contact info as you desire.
Your answer
Submit
Clear form
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google.
Report Abuse
-
Terms of Service
-
Privacy Policy
Forms
