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Naloxone Use Demographic Form
Naloxone is a medication used to counter an opioid overdose. Oakland County Community Mental Health Authority (OCCMHA) provides naloxone to local law enforcement in an effort to reverse an opioid overdose and save lives.

Law Enforcement – please use this form is to record demographic information for individuals assisted with naloxone.

Email address
Date of incident:
MM
/
DD
/
YYYY
Incident number (if applicable):
Your answer
City/zipe code:
Your answer
Was the "save" successful?
Required
Number of Naloxone kits used?
Your answer
Was an outreach card left at the scene?
Required
Gender:
Required
Age:
Your answer
Race/ethnicity (select one):
Required
For any questions, please contact Suzanne Weinert, OCCMHA at weinerts@occmha.org or 248-758-1991.
Note: Medication should be replaced when the expiration date passes. Request naloxone at www.occmha.org – Substance Use Disorders
A copy of your responses will be emailed to the address you provided.
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