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NALOXONE SURVEY FORM DATE OF REQUEST: NAME: NAME: TITLE: AGENCY: PHYSICAL ADDRESS1: PHYSICAL ADDRESS2: CITY/STATE/ZIP: COUNTY: TELEPHONE: EMAIL: Number of Dual Kit, IntraNasal Naloxone your organization

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Who needs naloxone survey form?

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Anyone who is interested in gathering data related to naloxone usage and awareness may need to fill out the naloxone survey form. This includes researchers, healthcare professionals, organizations working in the field of substance abuse, and individuals who have personal experiences with naloxone.

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What is naloxone survey form?

Naloxone survey form is a document used to collect information about the distribution and use of naloxone, a medication used to reverse opioid overdoses.

Who is required to file naloxone survey form?

Healthcare providers, pharmacies, and other entities that distribute naloxone are required to file the naloxone survey form.

How to fill out naloxone survey form?

The naloxone survey form can be filled out online or submitted via mail, and requires information about the quantity of naloxone distributed, the demographics of recipients, and any overdose reversals.

What is the purpose of naloxone survey form?

The purpose of the naloxone survey form is to track the distribution and usage of naloxone in order to monitor its effectiveness in reducing opioid overdose deaths.

What information must be reported on naloxone survey form?

Information such as the quantity of naloxone distributed, the type of naloxone (e.g. nasal spray or injection), the demographics of recipients, and any overdose reversals must be reported on the naloxone survey form.

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