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 *
Training Request Date & Time *
Provider/Agency name *
Is training for employees or clients? *
Contact person *
Contact person's email *
Contact person's telephone number *
Provider/Agency web address
Number of individuals to be trained *
Provider/Agency physical address (where training will occur if offsite)
Why do you need this training? *
What kind of training do you want? *
Has there been an overdose in your program? *
Are you hoping to get trained to save a life in your building or program?
Are you hoping to additionally get your patients, clients, residents or members trained and prescribed or dispensed naloxone (Narcan)? If so, by when?
Does your agency have a Medical Director?
Clear selection
Does your agency have an in-house, 340B or partner pharmacy?
Clear selection
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?
What are the options for parking in or around your agency (i.e. meter, street, private, etc.)?
Do you have a meeting space available to accommodate the number of individuals being trained?
Clear selection
Are you willing to have staff/members travel for training?
Clear selection
Please provide any additional information you feel that we need to know pertaining to your training request.
Please provide the names (first and last) of each individual participating in the training.
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