WHRC Staff Registration

Staff Information

Staff Member *

Participant Status *

New Returning

Naloxone Only

Yes No - Returning No - New

Participant ID Information

This creates the anonymous ID. Use "X" for middle initial if none.

First Initial *

Middle Initial *

Last Initial *

Birth Year *

County of Residence *

Participant ID Preview

___-____-___

Location Information

Location *

City *

County (for records) *

Naloxone Information

Naloxone Kits *

0 1 Other

Kit Serial #(s)

Since last visit, have you had a reversal? *

Yes No Unknown

Since last visit, used kit on someone else?

Yes No

County where reversal took place *

Was the overdose reported? *

Number of doses for reversal *

Type of kit used for reversal *

Notes

Registration Complete!

Participant has been registered successfully.

Access Code

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Participant ID

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