Narcan Request Form

Narcan Request Form
Your requested Narcan kit will be ready for pick up at Jackson County Public Health within one business day of your request. Please plan to pick up your kit within three business days.

You may use a nickname, initials, or the randomly-generated order number (below) in the "name" field if you prefer to stay anonymous.

One kit includes:
- 1-3 boxes of Narcan with instructions
- CPR face shield
- Safety plan and signs of overdose wallet cards
- Safety plan and signs of overdose magnets
- Printed treatment and recovery resources
- 10 fentanyl test strips with instructions
- Drawstring bag
Note: If you are requesting Narcan on behalf of an organization or are seeking more than 3 boxes of Narcan, please reach out directly to (816) 404-6493 or healthpromotions@uhkc.org.
Order number
What is today's date?*

MonthDayYear
Date
Name*
Your name will only be used to coordinate your Narcan kits for pick up. You may use a nickname, initials, or your order number (above).
What is your zip code?*
Type "NA" if you prefer not to answer.
What is your age?*

Under 18 years old18 - 24 years old25 - 34 years old35 - 44 years old45 - 54 years old55 - 64 years old65 - 74 years old75 years old or olderPrefer not to answer
What is your race?*

American Indian or Alaska NativeAsianBlack or African AmericanNative HawaiianTwo or more racesWhiteI only identify as Hispanic/LatinoPrefer not to answerOther
Do you identify as Hispanic or Latino/a/e?*

Yes, Hispanic or Latino/a/eNo, not Hispanic or Latino/a/ePrefer not to answer
How many boxes of Narcan would you like?*
One box of Narcan contains two (2) doses of intranasal naloxone
Have you ever used Narcan before?

YesNoI don't know
Would you like fentanyl test strips in your kit? (One pack = 10 test strips. Test strips are to be used only for testing substances, NOT testing urine samples.)*

YesNo
Email
example@example.com
Phone Number
Please enter a valid phone number.
Signs of an overdose
- Blue (lighter skin tones) or gray (darker skin tones) lips and fingertips
- Pale, clammy skin
- Small, pinpoint pupils
- Slow heartbeat and slow, irregular, or stopped breathing
- Not responding to voice or touch
How to administer Narcan

Narcan can reverse an opioid overdose. If someone has not used opioids (such as heroin, fentanyl, or prescription opioids), Narcan will have no effect on them. Narcan is safe for use in adults and children.
1. If you suspect someone is overdosing, call 911. The dispatcher can give you support and help you keep time until paramedics arrive.
2. Tilt the person's head back by putting your hand under their chin. Insert the white tip of the Narcan nasal spray into their nostril.
3. Push the red plunger down with your thumb until all of the spray is released into the nostril.
4. Remove the Narcan nasal spray from their nose and roll the person onto their side into the recovery position.
5. Talk to the person and let them know what is happening.
6. If they don't wake up/come to after 3 minutes, give them another dose of Narcan.
Safer use = overdose prevention
- If you are using opioids, have a safety plan. A safety plan might include taking turns using so someone close by can help in case of an overdose.
- Never use alone. Call the Never Use Alone hotline: 877-696-1996
- Use clean needles every time. If you have to reuse a needle, clean the syringe with cold, clean water and disinfect it with bleach for 2 minutes, then flush it out with cold, clean water again.
- Don't share needles.
- Start with a tester shot and go slow.
- Be careful when combining opioids with alcohol or benzos (such as Xanax or Klonopin). These combinations can increase the risk of overdose.
- Go slow, especially if you haven't used in 3 or more days or if you are changing the method. This can impact your tolerance and increase the risk of overdose.
- Test the substances for fentanyl. The presence of fentanyl drastically increases the chances of accidental overdose. Use fentanyl test strips to keep yourself and others safe.
By checking this box, I attest that I have reviewed the educational information above, including signs of an overdose, how to administer Narcan, and factors that increase the risk of overdose, and I am over the age of 18. I can return to Jackson County Public Health to pick up more Narcan kits at any point.*

I agree.
Should be Empty: