Opioid Overdose Reversal Form
For NEXT Distro, a project of Next Harm Reduction.
If you reversed more than one overdose (more than one person, date, or location) please fill out one form for each occurrence.
What is your relationship to the person who experienced the overdose?
What type of naloxone did you use?
How many doses of naloxone did you use? *
Did anyone else also give naloxone for this same overdose? If so were they
Date the naloxone was used, if you're not sure you can put the month/year. *
Your answer
What zipcode (or town/state) did the overdose occur? *
Your answer
Was this location a *
Was the person who experienced an overdose *
What is the person who experienced an overdose *
About how old were they? *
Your answer
Did the person who experienced the overdose *
Required
Do you know if the person who overdosed had used anything else? *
Required
Was the person who overdosed conscious before naloxone was used? *
Was the person who overdosed breathing before naloxone was used? *
Was rescue breathing performed? *
Were EMS (911) contacted? *
Did the person who overdosed survive? *
Please provide any other information that would be helpful in describing the overdose. *
Your answer
If you would like more naloxone sent to you, please include your name, SEP code, or the handle you choose when you originally enrolled in NEXT. *
Your answer
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