Naloxone Distribution Reporting Form
Please complete this form to report the distribution of naloxone kits. Your responses help track distribution and ensure proper follow-up.
Distributor Full Name
*
First Name
Last Name
Distributor Email Address
*
example@example.com
Distributor Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Date of Distribution
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Location of Distribution (Address or Site Name)
*
Type of Recipient
*
Individual (for personal use)
Organization/Agency
Community Event
Other
Number of Naloxone Kits Distributed
*
Form of Naloxone Distributed
*
Nasal Spray
Injectable (vial/syringe)
Auto-injector
Other
Was overdose response training provided with this distribution?
*
Yes
No
If training was provided, please describe the topics covered.
Purpose of Distribution
*
Preventative (no known overdose)
Post-overdose follow-up
At-risk individual or group
Other
Additional Notes or Comments
Submit Report
Should be Empty: