I Used My Naloxone

If you used naloxone on more than one occasion, please submit a separate form for each occasion.

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* What is your age?

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* How would you describe your gender?

Male

Female

Transgender

Gender Non-Conforming

Other

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* When did you use your naloxone?

Select a Date

Date

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* Which type of naloxone did you use?

Intranasal

Intramuscular

Evzio® Auto-injector

Narcan® Nasal Spray

Where did you use your naloxone?

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* Borough

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* Neighborhood

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* Address, Cross streets, or ZIP Code

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* How many doses of naloxone did you use on the person who overdosed?

One

Two

More than two

I don't know

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* When you used naloxone on the person who overdosed, did anyone call 911?

Yes

I don't know

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* Did the person who overdosed survive?

Yes

I don't know

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* In what setting did the overdose happen?

In my home or someone else's home

In a shelter or supportive housing

In a public place (e.g. park, subway, public restroom)

In a program (e.g. syringe exchange, drug treatment)

Other

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* Is there anything else that you think we should know?

Remember to get a refill so you will be prepared if you need to reverse another overdose.