Narcan Online Ordering Form

Location & Program Name: Syracuse University, 13244; Health Promotion

Please complete the form below to request a Narcan kit through the Health Promotion Office at the Barnes Center.

Name Name First Last
SU ID
Birthday Birthday / MM / DD YYYY
Phone Phone - ### - ### ####
Email
Postal / Zip Code
Acknowledgement
I successfully completed the virtual Narcan training by viewing the required video on the following date: I successfully completed the virtual Narcan training by viewing the required video on the following date: / MM / DD YYYY
Please read the following Syracuse University specific policy below:

12.1 Syracuse University encourages all community members to care for themselves and others. Therefore, when a student(s) or student organization initiates help from a campus or community resource for medical assistance related to alcohol and other drugs, the health and safety of the student at risk will be the University’s priority.

12.2 The student receiving medical assistance, and the student(s) or student organization who called for help, will not be referred to Community Standards for alleged violations of alcohol and other drug policies if the following apply:

The students involved cooperate with staff and first responders by providing honest and complete answers to their questions; and
The students involved meet with a member of Student Outreach and Support for a follow-up non-disciplinary (educational) meeting. Student Outreach and Support will reach out to students involved to set up a time to meet.

12.3 Failure to meet the two (2) requirements above may result in a referral to Community Standards.

12.4 A student receiving medical assistance, and the student(s) or student organization who initiates help, are eligible to use the Medical Amnesty Policy – Alcohol and Other Drugs on more than one occasion. However, repeated use of the policy may be a cause of higher concern for an individual’s well-being. Students involved in repeated use of this policy may be referred to the Barnes Center at the Arch for evaluation or Community Standards for possible conduct violations depending upon the relevant circumstances, after evaluation and assessment by the Associate Vice President and Dean of Students.

12.5 The Medical Amnesty Policy – Alcohol and Other Drugs only extends to situations in which medical assistance is sought and does not provide relief from referral to Community Standards for other possible violations of the Student Conduct Code.

12.6 For information on amnesty related to reports of sexual assault, sexual harassment, stalking or dating/domestic violence see Amnesty for Reporting Students in the Sexual Harassment, Abuse, and Prevention Policy. *

Please read the following Syracuse University specific policy below:

12.1 Syracuse University encourages all community members to care for themselves and others. Therefore, when a student(s) or student organization initiates help from a campus or community resource for medical assistance related to alcohol and other drugs, the health and safety of the student at risk will be the University’s priority.

12.2 The student receiving medical assistance, and the student(s) or student organization who called for help, will not be referred to Community Standards for alleged violations of alcohol and other drug policies if the following apply:

The students involved cooperate with staff and first responders by providing honest and complete answers to their questions; and
The students involved meet with a member of Student Outreach and Support for a follow-up non-disciplinary (educational) meeting. Student Outreach and Support will reach out to students involved to set up a time to meet.

12.3 Failure to meet the two (2) requirements above may result in a referral to Community Standards.

12.4 A student receiving medical assistance, and the student(s) or student organization who initiates help, are eligible to use the Medical Amnesty Policy – Alcohol and Other Drugs on more than one occasion. However, repeated use of the policy may be a cause of higher concern for an individual’s well-being. Students involved in repeated use of this policy may be referred to the Barnes Center at the Arch for evaluation or Community Standards for possible conduct violations depending upon the relevant circumstances, after evaluation and assessment by the Associate Vice President and Dean of Students.

12.5 The Medical Amnesty Policy – Alcohol and Other Drugs only extends to situations in which medical assistance is sought and does not provide relief from referral to Community Standards for other possible violations of the Student Conduct Code.

12.6 For information on amnesty related to reports of sexual assault, sexual harassment, stalking or dating/domestic violence see Amnesty for Reporting Students in the Sexual Harassment, Abuse, and Prevention Policy. * I understand that while New York State operates under the Good Samaritan Law, being on a college campus also means adhering to university guidelines. At Syracuse University, we follow the Medical Amnesty Policy.
By submitting this form, I am requesting one free Narcan kit for pickup at Health Promotion.

By submitting this form, I am requesting one free Narcan kit for pickup at Health Promotion. Yes No
I understand that it might take 24-48 hours for my Narcan kit to be ready for pick up at Health Promotion.

I understand that it might take 24-48 hours for my Narcan kit to be ready for pick up at Health Promotion. I understand.

Narcan Online Ordering Form

Narcan Online Ordering Form

Acknowledgement