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Naloxone Usage Form

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
Do you know the zip code where the overdose happened?
Did the person who overdosed survive? (choose one)
Select the type of naloxone used and the number of doses given (check all that apply)