NALOXONE REPLACEMENT SURVEY
PLEASE COMPLETE BEFORE REQUESTING A REPLACEMENT KIT
NALOXONE KIT NUMBER
DATE KIT WAS RECEIVED
/
Month
/
Day
Year
Date
REASON FOR REQUESTING A NEW KIT
*
USED
EXPIRED
LOST
OTHER
DATE KIT WAS USED
-
Month
-
Day
Year
Date
WHAT IS YOUR RELATIONSHIP TO THE PERSON THE KIT WAS USED ON?
FAMILY
FRIEND
STRANGER
OTHER
RESULT OF USE?
OVERDOSE REVERSED
DEATH
UNKNOWN
WAS 911 CALLED?
YES
NO
UNKNOWN
COUNTY OF RESIDENCY?
*
ST. CLAIR
GENESEE
LAPEER
SANILAC
OTHER
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