Qualtrics Survey | Qualtrics Experience Management

Student ID Number

Campus Email

Please tell us what you are requesting.

Narcan (1 box)
Fentanyl Test (5 tests)
Narcan and Fentanyl Tests

If you are unsure if an individual has overdosed, you should:

Administer Narcan
Call 911
None of the above

What are signs of a possible overdose?

Difficulty waking them up
Individual seems overly sleepy or confused
Breathing has slowed or stopped
Small pupils
Lips/fingernails are purple
All of the above

What can Narcan (naloxone) be used for?

All drugs
Opioids
Alcohol poisoning
All of the above

What are the three P's administering Narcan?

Peel, Place, then Press
Peel, Place, then Pull
Press, Place, then Peel
Pump, Plug, then Pull

What do you do after administering Narcan?

Roll individual onto left side
Roll individual onto right side
Pinch them
Splash them with water

I attest that I will call 911 if I administer Narcan (Naloxone) to any person.

Yes
No

By signing this form, I attest to the following:
- I have watched the training video
- All of the information submitted in the form is true and accurate, and I am submitting the form on my own behalf
- I am a current Cal State University of San Marcos student

Sign Here

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