Anonymous Naloxone use form
If you received Naloxone from our program and used it to reverse an overdose, use this form to report it. 
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Today's date
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Date that overdose occurred
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This survey is being completed by:
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Location where the overdose occurred (city/town/zip code):
What drugs were thought to be involved in the overdose?
How many doses of naloxone were given?
Is there anything else you would like to share with us?
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