Naloxone Dispensary Box Survey Filled out either before or after using a Naloxone Dispensary Box Step 1 of 3 33% 1. Is this survey being taken before or after using the Naloxone?(Required) Before After 2. How was this Naloxone received?(Required) Outreach by Hand Vending Machine 3. Where did you get this Naloxone?(Required) A2Z Bail Bonds Adrenaline Studios Tattoo Ankeny Free Church Bordenaro's Pizza Cha Cha Highland Baker Club G Covert Action The Despensary Drake University Eli Uli Shauuu LLC IHRC Faith Missionary Baptist Church Focuss Fort Des Moines Church of Christ Full Circle Recovery Community Center The Garden Grooming by Brenda Home Inc Maingate Bar & Grill Rise Recovery Center Stan's Part 2 Team Jesus Urban Dreams Community Center The Village Vinyl Records 4. Is this your first time accessing Naloxone?(Required) Yes No Unsure 5. If you weren't able to get Naloxone from this location, would you be able to get it from somewhere else?(Required) Yes No Unsure 6. Why are you getting Naloxone?(Required) Current Overdose I am around people who I worry will overdose I am worried I might overdoes Want to have it just in case Some other reason 7. Has Naloxone you received from this location helped reverse an overdoes in the past?(Required) Yes No Unsure 2. Was this Naloxone used on someone experiencing an overdose?(Required) Outreach by Hand Dispensary Box 3. Was the Naloxone effective at reversing the opioid overdose?(Required) Yes No Unsure 4. How many doses were used?(Required) 1 2 3 4 5 6+ 5. How was this Naloxone received?(Required) Ourtreach/By Hand Dispensary Box 6. Where did you get this Naloxone?(Required) A2Z Bail Bonds Adrenaline Studios Tattoo Ankeny Free Church Bordenaro's Pizza Cha Cha Highland Baker Club G Covert Action The Despensary Drake University Eli Uli Shauuu LLC IHRC Faith Missionary Baptist Church Focuss Fort Des Moines Church of Christ Full Circle Recovery Community Center The Garden Grooming by Brenda Home Inc Maingate Bar & Grill Rise Recovery Center Stan's Part 2 Team Jesus Urban Dreams Community Center The Village Vinyl Records 7. City of overdose?08. Was 911 called?(Required) Yes No 09. Did the individual go to the emergency department or hospital?(Required) Yes No Unsure 10. Has the individual experienced an overdose in the past?(Required) Yes No Unsure 11. Would you like to be connected with a recovery coach or support serivces?(Required) Yes No
