**If you have more than one overdose event to report please submit a separate survey for each one**

Your participation helps us get funding to save more lives, and provides important information to help us improve our work.  Thank you so much!
If you have another overdose event to report please click "Done" and then fill out a new survey for each event.  Thank you!

***If you would like to request Narcan/ Naloxone, please fill out a quick order request form by clicking HERE. We will get the reversal kit out to you ASAP.***

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* 1. Have you already reported this overdose reversal to The Chris Atwood Foundation in the past? If so please do not report the same incident twice. 

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* 2. When did this unreported overdose event occur?

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* 3. Did you administer naloxone to the overdose victim?

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* 4. How many doses of naloxone did you use?

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* 5. Did you call 911 or take the individual to the hospital?

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* 6. Was the overdose reversal successful?

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* 7. What county do you live in?

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* 8. Is there anything else you would like us to know about the event? Please include any comments you think would help us improve our outreach and training. 

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* 9. Can we have your email? Just in case, we need to contact you for more information about your reversal or we need to verify your address to send you another kit. 

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* 10. How did you hear about The Chris Atwood Foundation?

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