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 *
Your answer
Where did the overdose occur? *
When did the overdose occur? *
MM
/
DD
/
YYYY
Was Narcan/Naloxone administered? *
If yes, please provide the lot number of the Narcan/Naloxone kit(s) you administered.
Your answer
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.
Your answer
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.
Your answer
DC Health asks us to share demographic information about the person who experienced an overdose. What would you say is the person’s race? *
What is the person's age? *
What is the person's gender? *
What drug do you suspect the person was using? (please select all that apply) *
Required
Please describe any challenges or barriers experienced with Naloxone administration.
Your answer
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