Overdose Reversal Reporting Form

This form is used to report an overdose reversal where naloxone was administered. Your responses help programs like ours continue distributing naloxone & improving access to lifesaving resources.

The first section asks for basic details about the incident:

  • City, state, & zip code where the overdose occurred
  • Date of the incident 
  • Which brand of naloxone was used
  • How many doses were administered

These questions are required in order to complete the report. Summary data may be shared with public health agencies to support ongoing access to naloxone, but personal or identifying information is never shared.

At the end of this form, you will have the option to request replacement naloxone doses by mail at no cost. No credit card is required, & shipments are packaged & sent confidentially. Packages are typically shipped within 1–2 weeks on average.

If you are reporting more than one overdose, please fill out one form per incident.

Sign in to Google to save your progress. Learn more
City: (Required)
 *
State: (Required)
 *
Zip Code: (Required)
 *
Date of the Incident: (Required)
 *
Date
Which Brand of Naloxone was Administered: (Required)
 *
Number of Naloxone Administered: (Required)
 *
Are You Willing to Answer 10 Additional Questions: (Optional)
Clear selection
Next
Clear form
Never submit passwords through Google Forms.
This form was created inside of Harm Reduction Circle.

Does this form look suspicious? Report

Google Forms