Skip to content
FIND TREATMENT OR SUPPORT
SHARE YOUR STORY
REPORT AN OVERDOSE
NEWS & ALERTS
About Opioids
What Are Opioids?
Heroin vs. Prescription Opioids
Changes in the Brain
Dependence vs. Addiction
Other Health Risks
How Overdoses Happen
Prevention
Preventing Addiction
Developing Resiliency
Talk With Youth
Talk With Your Health Care Provider
Safely Store Medications
Take Back Your Meds
Preventing Overdoses & Deaths
Know the Signs and Symptoms of Overdose
Carry Naxolone
Find Treatment or Support
Medication-Assisted Treatment (MAT)
Resources
Virtual Overdose Awareness Vigil Resources
10 Things to Know About Opioids
Know Your Meds, Lock Your Meds
Take Back Unwanted Meds
Learn About Addiction
Know How to Help
Know Who to Call
Talk to Your Provider
Talk to Seniors
Talk to Your Kids
Get Involved
Give Responsibly
For Current Drug Users
For Needle Disposal
For Workplaces & Businesses
For Educators
For Providers & Prescribers
Community Presentations
Pregnancy and Opioid Use Disorder
News & Alerts
Seven Days of the Opioid Epidemic
Action Plan
Multi-Agency Coordination Group
HRSA Rural Communities Opioid Response Program Grant
Contact Us
Share Your Story
Report Use of Naloxone or Narcan
Data
Report Use of Naloxone or Narcan
Please enable JavaScript in your browser to complete this form.
Date of Overdose (or When Administered)
*
Patient Information (if known)
Male
Female
Other
Patient Name
Patient Age
Patient Race/Ethnicity
Location of Overdose (Address or Cross Street)
Type of Location
Own Residence
Someone Else’s Residence
Public Place (Like Store, Restaurant, Park, etc.)
Encampment
Vehicle
Other (please explain)
Other Information - Your Name
Your Email
*
Your Relationship To Patient
Spouse
Parent
Child
Other Family
Friend
Co-worker
Other
Where Did You Get The Naloxone Kit?
Pharmacy (Please Indicate Where)
Provider
Hospital
Syringe Exchange
Friend or Family Member
Other
General Data Protection Regulation Agreement
*
I consent to having the Snohomish Health District and Snohomish County contact me with follow-up questions, and sharing non-identifiable information with its partners and the general public.
Captcha
*
=
Message
Submit
FIND TREATMENT OR SUPPORT
