Prevention Point Philadelphia Overdose Reversal Training Request Form
Please fill out this form as completely as possible. After you submit the form, a Prevention Point employee will contact you to go over details and get your training scheduled.
Today's Date *
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Training Request Date & Time *
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Provider/Agency name *
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Is training for employees or clients? *
Contact person *
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Contact person's email *
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Contact person's telephone number *
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Provider/Agency web address
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Number of individuals to be trained *
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Provider/Agency physical address (where training will occur if offsite)
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Why do you need this training? *
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What kind of training do you want? *
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Has there been an overdose in your program? *
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Are you hoping to get trained to save a life in your building or program?
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Are you hoping to additionally get your patients, clients, residents or members trained and prescribed or dispensed naloxone (Narcan)? If so, by when?
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Does your agency have a Medical Director?
Does your agency have an in-house, 340B or partner pharmacy?
Is there a training/in-service day, staff meeting day, or member meetings that are held at your agency? If so, what day and time?
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What are the options for parking in or around your agency (i.e. meter, street, private, etc.)?
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Do you have a meeting space available to accommodate the number of individuals being trained?
Are you willing to have staff/members travel for training?
Please provide any additional information you feel that we need to know pertaining to your training request.
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Please provide the names (first and last) of each individual participating in the training.
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Comments
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