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Naloxone Accessibility Challenge Survey
Thank you for participating!
Home Page
Naloxone
Naloxone Accessibility Challenge
Survey
Email
Name
First
Last
Name and address of the location you visited
Location/Store Name
Address Line 2
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
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North Carolina
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Northern Mariana Islands
Ohio
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Puerto Rico
Rhode Island
South Carolina
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Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Date of your visit to this location
MM slash DD slash YYYY
Type of Location Visited
Pharmacy
Local Harm Reduction Agency
Local Health Department
Naloxone Vending Machine
Major Retail Store (Target, Walmart, etd)
Other
Who was the representative that assisted you? Check all that apply.
Pharmacist
Pharmacy Technician
Community Member
Local Harm Reduction Member
Other
If other, please describe:
Was the representative who assisted you familiar with dispensing naloxone upon request?
Yes
No
N/A
Was training on how to administer naloxone offered?
Yes
No
N/A
Was there signage for either Naloxone Availability or Narcan® OTC?
Yes
No
N/A
Did the location you visited carry Naloxone (in any form)?
Yes
No
N/A
Did the location you visited carry prescription naloxone?
Yes
No
N/A
Did the location you visited carry Naloxone OTC (over the counter)?
Yes
No
N/A
If Naloxone OTC is available, where was it located? (i.e. behind the pharmacy counter, on a shelf, locked up, etc.)
If the location carried Naloxone OTC, what was the cost?
Was the option presented to you to purchase prescription Naloxone through your specific state standing order or 3rd party access? (no purchase required)
Yes
No
N/A
Types of naloxone carried at this location (check all that apply)
Narcan® (Over the Counter)
Kloxxado®
Zimhi®
Generic nasal spray naloxone
Unsure of Name
No Naloxone Carried
Were you asked questions about why you needed naloxone?
Yes
No
N/A
Were you offered the option of purchasing naloxone as soon as you asked about it?
Yes
No
N/A
Did you actually purchase naloxone during this visit? (not required)
Yes
No
I was treated respectfully when asking for naloxone.
Strongly Agree
Agree
Neither Agree or Disagree
Disagree
Strongly Disagree
I have posted a photo on the following platforms using #naloxonesaveslives showcasing the signage at this location. (Check all that apply)
Instagram
X/Twitter
Facebook
Blue Sky
LinkedIn
Not listed
Additional Comments and/or concerns regarding the visit:
If the location did not have naloxone, why did they not have it in stock? (e.g., did they run out of it, do they not carry it, etc.)
Additional Comments and/or concerns regarding the lack of naloxone at the location:
Gender Identity
Male
Female
Transgender
Non-Binary
Prefer not to answer
Your Age Range
Under 18
18-29
30-45
46-60
Over 60
Prefer not to answer
Please specify your ethnicity (check all that apply)
African-American
Asian
Caucasian
Latino or Hispanic
Native American
Native Hawaiian or Pacific Islander
Prefer not to Say