Overdose Incident Form

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If you’ve responded to an opioid overdose recently or while using the naloxone given to you by Addicts Against Overdose or Kansas Recovery Network filling out this opioid overdose incident form is a necessity. Your responses will help us illustrate the importance of naloxone distribution, education, and harm reduction strategies.

- Your name is not required.

- If you responded to more than one overdose (more than one person, date, or location) please fill out one form for each occurrence.

Did you use Naloxone or Narcan to respond to someone overdosing? *

Yes

If used, where did you obtain the naloxone? *

What is your relationship with the person who experienced the overdose? *

If used, what kind of naloxone was used?

In what city/town did the overdose occur? *

What State did the overdose occur? *

What zip code was the naloxone used? *

Please provide the date the naloxone was used - at least the month and year.

YYYY

If used, how many doses of naloxone were used?

Was this location... *

Was the person who experienced the overdose... *

How old were they?

Has this person had an overdose in the past?

Yes

Maybe

Clear selection

Did the person who experienced the overdose... *

Inject heroin

Sniff heroin

Use heroin - unsure how

Not use heroin

Not sure

Required

Do you know if the person who overdosed used anything else? *

Methadone

Pain pills

Cocaine

Alcohol

Benzos

Amphetamine/methamphetamine

Fentanyl

Somethine else

Required

Was the person who overdosed conscious before naloxone was used?

Was the person who overdosed breathing before naloxone was used?

Was rescue breathing preformed? *

Were EMS (911) contacted? *

Did the person who overdosed survive? *

Any further information?

If you would like to be contacted for more naloxone or resources please leave contact information here - not required.

If you have a message you would be willing to anonymously give about why this program is important. Please include it here.

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