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"Save-a-Life" Naloxone Distribution Team
To be completed by partner agency staff members that will be assigned to the team for Naloxone outreach
* Indicates required question
Name
*
Your answer
Agency
*
Your answer
Email
*
Your answer
CELL Phone Number (to be shared with other team members)
*
Your answer
Is Your Agency a NYSDOH Registered OOPP (approved by NYSDOH to receive, train and distribute Naloxone)
*
Yes
No
Unsure
Please select the outreach schedule that works best for your availability
*
Monthly
Every two months
No preference
Required
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