JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.
Xylazine Positive Test Strip Report
Please submit as much information as possible in the form below if you have tested a sample suspected to contain xylazine. All information submitted is anonymous and is used solely for community public health purposes. If you would like to contact Drug Checking LA for questions or to coordinate testing the sample on the FTIR, please email checkingLA@proton.me
Sign in to Google
to save your progress.
Learn more
* Indicates required question
Substance Tested (i.e fentanyl, heroin, methamphetamine, cocaine, etc.)
*
Your answer
Xylazine Test Strip Result
*
Positive
Negative
Fentanyl Test Strip Result
*
Positive
Negative
Did Not Run
ZIP Code or Town where substance was obtained
*
Your answer
Additional Notes
Your answer
Submit
Clear form
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. -
Terms of Service
-
Privacy Policy
Does this form look suspicious?
Report
Forms
Help and feedback
Contact form owner
Help Forms improve
Report
