Overdose Reporting Form
This form is to report an overdose. You will remain anonymous (none of your information will be provided on this form). The information you provide is about the person who overdosed.
Date of overdose:
-
Month
-
Day
Year
Date
Person's name:
First Name
Last Name
Phone number:
Please enter a valid phone number.
Format: (000) 000-0000.
Address where overdose occurred (as close as you can get):
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Person's date of birth:
-
Month
-
Day
Year
Date
Fatal (death from overdose) or Non-fatal?
Fatal
Non-fatal
Person's gender:
Male
Female
Person's race:
Caucasian
African American
Hispanic or Latino
American Indian
Asian
Other
Does this person have a history of substance use?
Yes
No
Unknown
Does this person have a history of mental health issues?
Yes
No
Unknown
Do you think this person would benefit from an overdose kit (narcan, fentanyl/xylazine test strips, treatment resources, safe use education)?
Yes
No
Unknown
If you would like to provide more information or have questions, please contact the county harm reduction coordinator, Kayela Bennett at 270-668-7294 or kayela.bennett@ky.gov
Submit
Should be Empty: