Opioid Overdose Incident Form
Thank you for filling out this Opioid Overdose Incident Form. 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. Please reach out to jamie@nextdistro.org if you have any questions
Where did you get the naloxone? *
Required
What is your relationship to the person who experienced the overdose? *
What type of naloxone did you use? *
Required
In what town/city did the overdose occur? *
Your answer
In what state did the overdose occur? *
Your answer
In what zip code did the overdose occur?
Your answer
Please provide the date the naloxone was used. If you're not sure you can put the month/year. *
Your answer
How many doses of naloxone did you use? *
Was this location... *
Was the person who experienced an overdose *
What is the person who experienced an overdose *
Required
About how old were they? *
Your answer
Has this person experienced an overdose in the past?
Did the person who experienced the overdose *
Required
Do you know if the person who overdosed had used anything else? *
Required
Was the person who overdosed conscious before naloxone was used? *
Was the person who overdosed breathing before naloxone was used? *
Was rescue breathing performed? *
Were EMS (911) contacted? *
Did anyone else also give the person naloxone for the same overdose? *
If you answered "Yes" that someone else also gave the person naloxone for the same overdose, were they... (check all that apply)
If someone else gave the overdosing person naloxone, do you know what kind they used? If so, please describe.
Your answer
Did the person who overdosed survive? *
Please provide any other information that would be helpful in describing the overdose. *
Your answer
If you would like more naloxone sent to you, please include your name and an email or phone number. We will contact you to confirm your address, please look for our message. *
Your answer
Would you like us to call you to debrief the experience?
We are trying to raise money to build out our website and get more postage to send supplies to more people. If you have a message you would be willing to anonymously give about why this program is important. Please include it here.
Your answer
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