NALOXONE KIT REQUEST FORM
Date of Request
*
-
Month
-
Day
Year
Date
ORGANIZATION/AGENCY
Phone Number
*
Please enter a valid phone number.
Email
*
example@example.com
Race/Ethnicity (CHECK ALL THAT APPLY).
American Indian - Peoria Tribe Citizen
American Indian/Alaska Native - Other Tribe
Black/African American
Hispanic/Latino
White/Caucasian
Asian
Native Hawaiian/Pacific Islander
Reason for Request
*
New kit
Administered Kit
Broken/lost kit
Kit expired
Other
Date of overdose
-
Month
-
Day
Year
Date
Time of overdose
Hour Minutes
AM
PM
AM/PM Option
Zip code where overdose occurred
If Known, Race/Ethnicity of PERSON WHO OVERDOSED (CHECK ALL THAT APPLY).
American Indian - Peoria Tribe Citizen
American Indian/Alaska Native - Other Tribe
Black/African American
Hispanic/Latino
White/Caucasion
Asian
Native Hawaiin/Pacific Islander
Unknown
If known, Gender of the PERSON WHO OVERDOSED
Male
Female
Unknown
Other
Signs of Overdose Present (CHECK ALL THAT APPLY).
Unresponsive
Slow pulse
Breathing slowly
No pulse
Not breathing
Blue lips
Other
Overdosed on what drugs? (CHECK ALL THAT APPLY).
Heroin
Benzos/barbiturates
Stimulants
Prescription Opioids
Don't Know
Other
Was Naloxone given during overdose?
Yes
No
Don't know
If YES, number of doses used
Was the person alive the last time you observed them
Yes
No
Not sure
Notes/Comments
Name of Person to Receive Naloxone Kit?
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
FOR ANY QUESTIONS. PLEASE CONTACT PEER RECOVERY SERVICES OFFICE AT 918-544-6663.
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