Naloxone Administration Survey
The purpose of this survey is to determine the setting, population, and outcome of your recent naloxone administration. Completion of this survey will help assess opioid overdose and naloxone use in the state of Wyoming. This survey will take approximately 5 minutes to complete. Your answers will be kept confidential and will only be reported to the Wyoming Department of Health.
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Email *
1. Date of Naloxone Administration *
2. Gender of person receiving naloxone *
3. What county was the naloxone administered? *
4. I am a(n)... *
5. What form of naloxone was used? *
6. Number of naloxone doses given... *
7. Types of drugs involved (Check all that apply): *
8. Was 911 called? *
9. What was the outcome of the naloxone administration? *
10. To your knowledge, did the individual survive?
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11. Was the individual transported to the hospital? (Select One) *
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This form was created inside of State of Wyoming. Report Abuse