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REPORT AN OVERDOSE
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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
Resources
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Report Use of Naloxone or Narcan
Data
Report Use of Naloxone or Narcan
Date of Overdose (or When Administered)
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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
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Your Relationship To Patient
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Parent
Child
Other Family
Friend
Co-worker
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Where Did You Get The Naloxone Kit?
Pharmacy (Please Indicate Where)
Provider
Hospital
Syringe Exchange
Friend or Family Member
Other
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