Pharmacy Overdose Reversal Reporting Form

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* Pharmacy Name

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* Supervising Pharmacist

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* Pharmacy Address

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* Contact Phone

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* Contact Email

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* Pharmacist Submitting Form

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* Date Submitted (approximate date is sufficient)

Select a Date

Date

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* Describe reported overdose reversal/naloxone use

Yes

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* What type of naloxone was used?

Intramuscular

Intranasal

Auto-injector

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* How many doses of naloxone were used?

One

Two

More than two

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* On what date was naloxone used? (Approximate date is sufficient)

Select a Date

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* Where was naloxone used? (Borough/Neighborhood/Cross-Streets/ZIP)

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* Was 911 called when the person overdosed?

Yes

I don't know

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* Did the person survive?

Yes

I don't know

Pharmacy Overdose Reversal Reporting Form

Question Title

* Pharmacy Name

Question Title

* Supervising Pharmacist

Question Title

* Pharmacy Address

Question Title

* Contact Phone

Question Title

* Contact Email

Question Title

* Pharmacist Submitting Form

Question Title

* Date Submitted (approximate date is sufficient)

Question Title

* Describe reported overdose reversal/naloxone use

Question Title

* What type of naloxone was used?

Question Title

* How many doses of naloxone were used?

Question Title

* On what date was naloxone used? (Approximate date is sufficient)

Question Title

* Where was naloxone used? (Borough/Neighborhood/Cross-Streets/ZIP)

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* Was 911 called when the person overdosed?

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* Did the person survive?

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* Please share any other information about the event