Naloxone Reporting Form

Thank you for saving a life and thank you for letting us know!

This is a reporting system for the administration of Naloxone, in the event of a suspected opioid overdose. PLEASE ONLY FILL OUT IF YOU HAVE ADMINISTERED NALOXONE.

Thank you for providing this information, which will be used to demonstrate program success in an attempt to secure future funding for REVIVE! Your responses are completely anonymous, and will only be shared in aggregate form. Please answer only the questions you feel comfortable responding to. Thank you for being a part of REVIVE! and helping to save someone's life.

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* 1. City

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* 2. Zip Code

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* 3. Did you give naloxone to a person overdosing?

Yes

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* 4. Date

Date / Time

Date

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* 5. What happened after you gave naloxone?

The person started breathing

The person didn't respond

Other (please specify)

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* 6. Did you or someone else call 911 to report the overdose?

Yes

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* 7. Did 911 respond immediately?

Yes

n/a

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* 8. How many doses of naloxone did you administer?

One

Two

Other (please specify)

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* 9. Please provide any additional information you'd like to share. If you are interested in being contacted please leave your contact information below.