Anonymous Overdose Reversal Report Form
You can use this form to report using naloxone/Narcan to reverse an opioid overdose. This form is intended for laypeople administering naloxone in the community, not first responders or healthcare providers administering naloxone in the course of their job. This reporting is anonymous and no personally identifying information is asked for. Gathering information about overdose reversals helps guide, inform, and support NCHRC's overdose prevention outreach. 
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What month and year did the overdose reversal happen in? *
Did the person who overdosed survive? *
In what NC County did the overdose reversal happen in? *
What kind of naloxone kit was used to reverse the overdose? Leave blank if you don't know. 
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How many doses of naloxone were used to reverse the overdose? Leave blank if you don't know.
If more than one dose was used, do you know about how long passed between doses being administered? Leave blank if you don't know.
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Is there anything else you would like to share about what happened? (No personally identifying information please.)
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This form was created inside of North Carolina Harm Reduction Coalition.

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