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

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

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