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?

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* When did you use your naloxone?

Date

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* Which type of naloxone did you use?   

Where did you use your naloxone?

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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?

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

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* Did the person who overdosed survive?

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* In what setting did the overdose happen?

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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.

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