"Narcan Reporting Form"
Thank you for reporting usage of your Narcan kit. All information you provide is anonymous. Knowing how many lives are saved will help us report to our funders to keep this program running and help us better understand the needs of our community.

You can request a replacement kit by calling 413-587-4930, which can be sent by mail or picked up in person.

Hampshire HOPE is a county wide effort made up of advocates, leaders and organizations from our community, such as public health, healthcare, behavioral health, harm reduction, schools, recovery centers, the Northwestern District Attorney’s Office, first responders, police departments, and other justice related agencies.

If you or someone you love would like support, please contact our Drug Addiction and Recovery Team (DART) program at 413-588-2335 or HampshireHOPE@northamptonma.gov. DART is a collaboration between police and recovery coaches who assist people at risk for or have experienced an overdose, as well as family members who would like support connecting to area resources.

Where did you get the narcan used?
What date was the narcan used? *
MM
/
DD
/
YYYY
What time of day was the narcan used? *
Time
:
Where did the overdose occur? *
If other, please note
Your answer
Please check if anyone else, besides you, administered Narcan. You can check more than one box. *
Required
Where did you get the Narcan used?
Your answer
What city or town was the Narcan used in? *
If other, please list town.
Your answer
Age of the person who used narcan? *
What is the gender of the person who used narcan? *
What is the race of the person who used narcan? *
What town does the person who overdosed live? *
If other, please list town.
Your answer
Is the person that overdosed homeless? *
Is the person that overdosed a veteran? *
Has this person experienced an overdosed before? *
If yes, how many times (approximately)?
Your answer
Did the person who overdosed go to the hospital? *
Outcome *
Submit
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