Naloxone Usage Form Question Title * On what day was the naloxone used? (If naloxone was used on more than one day, please submit a separate report for each use. If you don’t know the precise date, choose one that you think is close.) (Required.) Date Date Question Title * Do you know the zip code where the overdose happened? Yes: Zip Code: No: County/Borough & Town Outside NYS Outside of New York State Question Title * Did the person who overdosed survive? (choose one) Yes No Don’t know Question Title * Select the type of naloxone used and the number of doses given (check all that apply) Narcan™ Nasal Intramuscular injection Nasal spray generic Evzio Autoinjector Don't know Next
