OVERDOSE REVERSAL REPORTING FORM
Knowing that the naloxone we distribute has been administered to someone experiencing an opioid overdose is crucial to measurement of our reach & impact across Arizona.  Thank you so much for trusting us with this information.  You will not be required to provide any individually identifiable information on this form.  If you have any questions or concerns about overdose reversal reporting, please email training@spwaz.org or call our main hotline at 480-442-7086.
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City in which overdose reversal occurred (if known - otherwise, please use city in which overdose reversal was reported) *
ZIP code in which overdose reversal occurred (if known - otherwise, please use ZIP code in which overdose reversal was reported)
County in which overdose reversal occurred (if known - otherwise, please use county in which overdose reversal was reported)
How many overdose reversals are you reporting for the location information entered above? *
Date this overdose reversal occurred (if known - you can also put today's date if date of reversal is unknown or you're reporting a bunch of reversals for this location) *
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Are you reporting this overdose reversal information as a: (Select only one) *
Are you associated with a community organization or agency that you'd like to name?  If so, please do so below.
Is there anything else you'd like us to know about the overdose reversal you're reporting here?
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