Please return this form to: courtneyponder@monroecounty.gov
Department of Public Health
Monroe County, New York
Naloxone Trained Overdose Responder Enrollment Form
Training available every Thursday at 2pm
Training Information
Date Planning to Attend: Location:
Trained Overdose Responder
Name: Birth Date: / /
(optional)
MM DD YYYY
Phone: E-mail:
Address:
City: State: Zip Code:
Race/ethnicity: Gender:
White Male
Black Female
Hispanic Transgender
Asian and Pacific Islander
Native American
Mixed Race
Unknown
Other (specify):
Do you fall into one of these categories?
Law Enforcement Personnel Firefighting Personnel Emergency Medical Staff (EMS)
School Personnel Library Staff
Commercial Businesses (such as restaurants, construction etc.)
Other (e.g. consumer, community provider, etc.)
-----------------------------------------------------Bottom Portion to be Completed by Trainer----------------------------------------------------
Naloxone and related equipment provided:
One box: Two intranasal spray devices 4 mg/0.1ml each
Expiration Date: /
MM YY
Approved Opioid Overdose Trainer:
Date: Name: Signature:
