HERC Naloxone Distribution Form

Please fill out the information below so that we may distribute to your office/department. Staff/Faculty are allowed to request Naloxone on hand for personal use or to partner as a distribution point on campus. If you have any questions, please contact the HERC at 217-581-7786 or Herc@eiu.edu

Name Name First Last
Department/Office
What is your purpose for requesting Naloxone (please note, this is for our tracking purposes only)

What is your purpose for requesting Naloxone (please note, this is for our tracking purposes only) Personal Use/Safety First-Aid Kit To have in department/office Other
Would you be willing to partner with the HERC to be an additional distribution center on campus?

Would you be willing to partner with the HERC to be an additional distribution center on campus? Yes No Would like to know more before committing
How many units of Naloxone (one unit=1 box with 2 doses) would you like to request?
If you are interested in a training to recognize and respond to opioid overdoses, please indicate below and the number of individuals you think may be interested in participating.