Overdose Reversal Reporting Form

Where did you obtain the naloxone?* This field is required.

Local harm reduction program

Pharmacy

Florida Department of Children and Families Naloxone Program

Friend

Someone else had it

Other

What is your relationship to the survivor?* This field is required.

Friend/Acquaintence

I experienced the overdose-someone narcan'd me

Wife/Husband/Partner

Family member

Stranger

Prefer Not to Answer

What kind of naloxone was used?* This field is required.

Intramuscular Naloxone (with syringe)

Narcan brand naloxone (one hand spray)

In what state did the reversal occur?* This field is required.

In what zipcode did this reversal occur?* This field is required.

Please provide the date this reversal occurred* This field is required.Or give best estimate

Date

How many doses of naloxone were used?* This field is required.How many doses were administered until person was revived

Was this location:* This field is required.

Home or Apartment

Shelter

A business such as a store, bar, etc

Syringe Exchange, drug treatment, social service

Public Place Outside

A library

A college/university

A middle school/high school

Other

Was the person's gender identity:* This field is required.

Was the person who experienced the overdose...* This field is required.

How old were they?* This field is required.

Has the person experienced an overdose in the past?* This field is required.

Yes

Not Sure

Did the person who overdosed...* This field is required.

Do you know if the person who overdosed had used anything else?* This field is required.

Methadone

Pain pills

Cocaine

Alcohol

Benzos

Amphetamine/Methamphetamine

Fentanyl

Something Else

Don't know

Was the person conscious before naloxone was used?* This field is required.

Yes

Unknown

Was the person breathing before naloxone was used?* This field is required.

Yes

Unknown

Was rescue breathing performed?* This field is required.

Yes

Unknown

Were EMS (911) Contacted?* This field is required.

Yes

Unknown

Did the person survive?* This field is required.

Yes

Unknown

Please provide any other information you think would be helpful:

Overdose Reversal Reporting Form