Overdose Reversal Reporting Form

Our Overdose Reversal Reporting Form is just 3 questions & takes less than 60 seconds. Your answers help ensure programs like ours can continue to distribute Naloxone to individuals like yourself.

If you are reporting more than one overdose please fill out one form per incident.

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City: (Required)
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State: (Required)
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Zip Code: (Required)
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Date of the Incident: (Required)
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MM
/
DD
/
YYYY
Which Brand of Naloxone was Administered: (Required)
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Number of Naloxone Administered: (Required)
 *
Are You Willing to Answer 10 Additional Questions: (Optional)
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