• Naloxone Use Report

  • Prefix
  •  -
  • What is your relationship to the person who overdosed?*
  • Date of Overdose*
     - -
    2 digit month, 2 digit day, 4 digit year
  • What opioid was the overdose caused by?*
  • Were there more than just opioids involved in the overdose?*
  • If more than opioids were involved, what other drugs were used?
  • How long was the person unresponsive before Naloxone was used?*
  • Was rescue breathing done?*
  • Was a breathing barrier used?*
  • Did the overdose return as the Naloxone wore off?*
  • If the overdose returned, how long did it take before it returned?
  • Was 911 Called?*
  • Did the Person receive emergency medical attention?*
  • Did the person live?*
  • Should be Empty: