Opioid Overdose Reporting Form
Please submit this form each time an opioid related-overdose occurs. This information is required by DC Health in order to participate in the Naloxone Distribution Program.
Opioids include: heroin, fentanyl, carfentanil, methadone, prescription pain killers, and morphine.
Your Name and Phone Number
Where did the overdose occur?
801 East Shelter: 2700 Martin Luther King Jr. Ave, SE
New York Avenue Shelter: 1355 New York Avenue, NE
Adams Place Shelter & Drop-In Center: 2210 Adams Place, NE
Harriet Tubman Shelter & Day Center: 1900 Massachusetts Ave SE, Bldg. 27
Patricia Handy Place for Women: 810 5th St. NW
Nativity Shelter for Women: 6010 Georgia Ave., NW
Downtown Day Services Center: 1313 New York Ave NW
When did the overdose occur?
Was Narcan/Naloxone administered?
If yes, please provide the lot number of the Narcan/Naloxone kit(s) you administered.
How many doses of Narcan were administered?
Was the overdose reversal successful?
For unsuccessful or fatal overdoses, explain any significant and relevant circumstances around these cases.
Was the individual transported to the hospital?
Did you refer the individual to treatment?
Have you submitted a Unusual Incident Report for the overdose?
If yes, please enter the allegation/complain number of the UIR.
DC Health asks us to share demographic information about the person who experienced an overdose. What would you say is the person’s race?
American Indian/Alaskan Native
Native Hawaiian/Pacific Islander
What is the person's age?
18 to 25
26 to 40
41 to 56
What is the person's gender?
Transgender - Male to Female
Transgender - Female to Male
What drug do you suspect the person was using? (please select all that apply)
Prescription pain killers
Please describe any challenges or barriers experienced with Naloxone administration.
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