I Used My Naloxone

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

Question Title

What is your age?

Question Title

How would you describe your gender?

Male

Female

Transgender

Gender Non-Conforming

Other

Question Title

When did you use your naloxone? (Required.)

Select a Date

Date

Question Title

Which type of naloxone did you use? (Required.)

Intranasal

Intramuscular

Evzio® Auto-injector

Narcan® Nasal Spray

Where did you use your naloxone?

Question Title

Borough (Required.)

Question Title

Neighborhood (Required.)

Question Title

Address, Cross streets, or ZIP Code

Question Title

How many doses of naloxone did you use on the person who overdosed? (Required.)

One

Two

More than two

I don't know

Question Title

When you used naloxone on the person who overdosed, did anyone call 911? (Required.)

Yes

I don't know

Question Title

Did the person who overdosed survive? (Required.)

Yes

I don't know

Question Title

In what setting did the overdose happen? (Required.)

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

Question Title

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.

I Used My Naloxone

Question Title

* What is your age?

Question Title

* How would you describe your gender?

Question Title

* When did you use your naloxone? (Required.)

Question Title

* Which type of naloxone did you use? (Required.)

Question Title

* Borough (Required.)

Question Title

* Neighborhood (Required.)

Question Title

* Address, Cross streets, or ZIP Code

Question Title

* How many doses of naloxone did you use on the person who overdosed? (Required.)

Question Title

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

Question Title

* Did the person who overdosed survive? (Required.)

Question Title

* In what setting did the overdose happen? (Required.)

Question Title

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

What is your age?

How would you describe your gender?

When did you use your naloxone? (Required.)

Which type of naloxone did you use? (Required.)

Borough (Required.)

Neighborhood (Required.)

Address, Cross streets, or ZIP Code

How many doses of naloxone did you use on the person who overdosed? (Required.)

When you used naloxone on the person who overdosed, did anyone call 911? (Required.)

Did the person who overdosed survive? (Required.)

In what setting did the overdose happen? (Required.)

Is there anything else that you think we should know?