Opioid Overdose Incident Form
Have you used naloxone that you or someone you know received from Save Our Families? If so, please fill out this form with as much information as you are comfortable sharing.

Note: Please do NOT submit this form if your naloxone was not provided by Save Our Families or another organization with the Project Dawn Network. We ask that you please contact the organization you received the naloxone from in order to provide them with this information.

If you have used your naloxone and would like to receive more, please contact us directly. 
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Email *
Where did you obtain the naloxone?
 *
What is your relationship to the person who experienced the overdose?
 *
Was the person successfully revived? *
Please identify gender of the person who overdosed. *
Age of the person who overdosed?
(If unknown, put "NA") *
Location of the incident? (Ex: Home, Work, Public Library, Park) *
In what city did the overdose occur? *
In what state did the overdose occur?
 *
In what zip code did the overdose occur?
 *
Was EMS (911) contacted?
 *
Was rescue breathing performed?
 *
Was the person who overdosed conscious before naloxone was used?
 *
What type of naloxone was administered? *
How many doses of naloxone were administered?
 *
What substance(s) were used during the time of the overdose?
Check all that apply.  *
Required
Was the substance tested with fentanyl or xylazine testing strips? (Select Only 1) *
Required
Is there any other information that would help describe the overdose and use of naloxone? 

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