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Report Use of Naloxone or Narcan

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.

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Name

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