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Pharmacy Name (Required.)

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Supervising Pharmacist (Required.)

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Pharmacy Address (Required.)

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Contact Phone (Required.)

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Contact Email (Required.)

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Pharmacist Submitting Form

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Date Submitted (approximate date is sufficient) (Required.)

Date

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Describe reported overdose reversal/naloxone use (Required.)

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What type of naloxone was used?

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How many doses of naloxone were used?

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

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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? (Required.)

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Please share any other information about the event

T