Report Use of Narcan/ Naloxone

Date of Overdose (or When Administered) *

How many doses were used? *

Naloxone Recipient Gender

Naloxone Recipient Age

Naloxone Recipient Race/Ethnicity

Zip Code of Overdose

Type of Location

If you selected other, please specify here. Please also add any other information you want to add for location type here.

Your Name

Your Email *

Who administered the naloxone? *

If you selected other, please specify here.

Where Did You Get The Naloxone Kit? *

If you selected pharmacy or other, please specify here.

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 *

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