Overdose Incident Report Form
If you’ve responded to an overdose recently in Central Oregon and have not reported it to a Harm Reduction Program and/or 911 was not called then please fill out this form anonymously! Filling out this overdose incident form is a necessity, every story deserves to be heard. Your responses will help us illustrate the importance of naloxone distribution, education, and harm reduction strategies.

- Your name is not required.

- If you responded to more than one overdose (more than one person, date, or location) please fill out one form for each occurrence.
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Did you use Naloxone or Narcan to respond to someone overdosing - or did someone use it on you?  *
If used, what kind of Naloxone as administered? *
How many doses of Naloxone were used?  *
Is Naloxone/Narcan was used, where was it obtained? *
Please provide the estimated date the overdose occurred *
Date
In what city, town, or zip code did the overdose occur  *
What was your relationship with the person who experienced the overdose?
Was the person who experienced the overdose recently released from...
Was the location.. *
Was the person who experienced the overdose...
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Was the person who experienced the overdose...
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How old were they?
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Has the person who experienced the overdose had an overdose in the past?
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If known, what substance was used *
Required
If used, was the person who overdosed conscious before naloxone was used?
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Was the person breathing before Naloxone was used?
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Was rescue breathing preformed? 
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Was 911/EMS called or was the person taken to the hospital? *
Did the person survive? *
If there is any further information you want to provide, please out it here. 
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