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NYSDOH Opioid Overdose Prevention Initiative

If you or someone else is experiencing a medical emergency, please call 911.  Please use this form to report naloxone use.  We provide the public with overdose prevention training over the phone and free naloxone.  Please call (607) 762-2622 Monday through Friday from 9 a.m. to 3 p.m. to access our overdose prevention services.

Community Naloxone Usage Form

If naloxone was used on more than one day, please submit a separate report for each use. If you don’t know the precise date, choose one that you think is close.
Did the person who overdosed survive?
Narcan
Narcan™ Nasal spray doses:
Narcan
Intramuscular injection generic doses:
Narcan
Nasal spray generic doses:
Narcan
Evzio Autoinjector doses:
Did anyone else also give naloxone for this same overdose? (choose one)
(Check all that apply) Were they
Do you know what type of naloxone they used?
Narcan
Narcan™ Nasal spray doses:
Narcan
Intramuscular injection generic doses:
Narcan
Nasal spray generic doses:
Narcan
Evzio Autoinjector doses:
Was 911 called? (choose one)
Was rescue breathing performed before EMS, police or fire fighters arrived? (choose one)
Were they
Were they (more than one may be selected)
(Indicate all that apply) Select which drugs the overdoser is likely to have used.
In what kind of place did the overdose happen?
What is the relationship between the person who overdosed and the responder?
Has this person experienced an opioid overdose in the past? (choose one)
Was a replacement kit given? (choose one)
Was information provided about getting naloxone from a pharmacy? (choose one)

Thank you for taking the time to complete this form. All program data submitted are confidential.