Overdose Response Survey

1.Have you responded to an overdose in 2024?

Yes- If yes, when?

No- If you witnessed or heard of an overdose, please continue with that information.

Date Overdose Occurred

2.Specify where overdose took place. (Apartment complex name, street name, camp name, etc.)

3.What is the victims age/gender identity?

4.Was Naloxone/Narcan administered?

Yes- If yes, how many?

No

Number of doses administered.

5.Was 911 Called?

Yes- Person was transported to the Emergency Department

Yes- Person refused transport

No- Person was taken to the Emergency Department

No- No other medical intervention

6.Did the person think fentanyl was in the drug?

Yes

No

What substance did the person think they were using?