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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. Steuben County is able to offer a free replenishment Narcan kit to county residents who administered Narcan and submit the form below. Training and Narcan are provided by Steuben County Public Health, a registered opioid overdose prevention program.

4. To receive a new FREE NARCAN KIT, please enter your name and mailing address. If you have questions, call 607-664-2438.

   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.

16. Please check this box if you would like to be contacted by a recover peer advocate.

    1. I would like to receive confidential peer support.

    Peers engage and connect individuals to local services by utilizing their recovery expertise, professional training, and lived experience.

18. 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.

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

    1. Yes
    2. No
21. 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
23. What was the patient's gender?*

    1. Female
    2. Male
    3. Transgender
    4. Other
24. What is the patient's race/ethnicity?*

    1. White / Caucasian
    2. Black / African-American
    3. Hispanic / Latino
    4. American Indian / Alaska Native
    5. Asian
    6. Native Hawaiian / Other Pacific Islander
    7. Middle Eastern / North African
    8. Other
26. Where did you get the Narcan from?*

    1. This website
    2. Narcan training event
    3. Pharmacy
    4. Healthcare or other service provider
    5. Hospital
    6. Family member or friend
    7. Wall-mounted box in/on a building
    8. Syringe exchange program
27. Did anyone bring the patient to the emergency room?*

    1. Yes
    2. No
    3. Unknown
29. Did anyone call 911?*

    1. Yes
    2. No
    3. Unknown
30. Did the patient survive the overdose?*

    1. Yes
    2. No
    3. Unknown
32. When did the overdose happen (month/year)?*
33. Where did the overdose happen (city/town/village)?*
35. 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, or shelter
    6. Other
37. Thank you for responding to an overdose emergency!

    Be on the lookout for your free Narcan kit in the mail.

Leave This Blank:


39. 1. Receive an email copy of this form.
40. Email address

    This field is not part of the form submission.

41. Submit Submit and Print

* indicates a required field