Naloxone Training & Naloxone Kit Request Form

Naloxone Training & Naloxone Kit Request Form

Name of Requester*

Requester's Email Address*

*Work email address only (umm.edu, som.umaryland.edu, etc.)

Requester's Best Contact Phone Number*

Phone

What are you requesting?*

Naloxone Training with Naloxone Kits Supplied

Naloxone Training without Naloxone Kits

Naloxone Kits Only

Reason for request**

Please include a brief description of the target audience for the training and/or kits (for example: “Year 1 SOM students”, “MSW students who are fellows in a behavioral health fellowship”, campus security staff, etc.)

Training Requests:

***At least four weeks notice is preferred to best accommodate your request. We ask that you provide a backup date/time as well in case we can't accommodate your first request.

Naloxone Kit Requests:

*** Kit requests should be submitted at least two weeks prior to the date required to ensure product availability

Facility Requesting Training*

School of Dentistry

Graduate School

School of Medicine

School of Nursing

School of Pharmacy

School of Social Work

Carey School of Law

Other

Enter "other" facility below*

Which facility are you from?*

School of Dentistry

Graduate School

School of Medicine

School of Nursing

School of Pharmacy

School of Social Work

Carey School of Law

Other

Enter "other" facility below*

Preferred Training Date (choice 1)*

Preferred Training Date (choice 2)*

How many people will be attending this training?*

please enter a whole number only

How many people will be attending this training?*

Kits will be supplied for the amount of attendees indicated below. 1 kit per person

Have you already made arrangements with an approved trainer in your area/school/department?*

Selected Location: School of Medicine

Yes

No

School of Medicine Trainers *

Your selected trainer will be notified of this request, prior communication is encourage before selecting their name.

Select or enter value

Do you already have a trainer from your location identified to conduct this requested training?*

Selected Location: School of Dentistry

Yes

No

School Of Dentistry Trainers *

Your selected trainer will be notified of this request, prior communication is encourage before selecting their name.

Select or enter value

Do you already have a trainer from your location identified to conduct this requested training?*

Selected Location: School of Nursing

Yes

No

School of Nursing Trainers *

Your selected trainer will be notified of this request, prior communication is encourage before selecting their name.

Select or enter value

Do you already have a trainer from your location identified to conduct this requested training?*

Selected Location: Graduate School

Yes

No

Graduate School Trianers *

Your selected trainer will be notified of this request, prior communication is encourage before selecting their name.

Select or enter value

Do you already have a trainer from your location identified to conduct this requested training?*

Selected Location: School of Social Work

Yes

No

School of Social Work Trainers

Your selected trainer will be notified of this request, prior communication is encourage before selecting their name.

Select or enter value

Do you already have a trainer from your location identified to conduct this requested training?*

Selected Location: School of Pharmacy

Yes

No

School of Pharmacy Trainers*

Your selected trainer will be notified of this request, prior communication is encourage before selecting their name.

Select

Do you already have a trainer from your location identified to conduct this requested training?*

Selected Location: Carey School of Law

Yes

No

Carey School of Law Trainers*

Your selected trainer will be notified of this request, prior communication is encourage before selecting their name.

Select

What is the total number of naloxone kits you will need?*

** 1 kit per person will be supplied

What date do you need the Naloxone kits delivered by?*

**We will email you to coordinate a precise delivery date and time prior to the date you select

Is there another contact you would like included in communications about this request?*

Yes

No

Other Point of Contact Name*

Other Point of Contact Email Address*

Other Point of Contact Phone Number*

Phone

By checking the below box, I agree that all completed ORP Trainee Registration Forms and any naloxone kits not distributed at the scheduled training(s) will be returned to the supplying ORP (The Kahlert Institute for Addiction Medicine) upon completion of the training.

Send me a copy of my responses

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