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Community Naloxone Usage Form

Naloxone Usage Reporting Form

This form helps us understand how the naloxone we provide is being used in our community. All responses are completely anonymous.

* Required Fields

1. On what day was the naloxone used? (if naloxone was used on more than one day, please fill out a separate form for each use. If you don't know the exact date, choose one that you think is close)

2. What was the city/town where the overdose happened? (If you don't know the location, write "I don't know.")

3. Did the person who overdosed survive?

Yes No Don't know

4. How many doses of naloxone did you give the person?

5. Did anyone else also give the person naloxone for the same overdose?

Yes No Don't know

6. If yes, were they...

7. Did someone call 911?

Yes No Don't know

8. Did you or another witness/bystander perform CPR before first responders arrived?

9. How old was the person who overdosed (best guess)?

10. What was their gender?

11. What was their race/ethnicity? (Select all that apply)

African-American/Black Asian/Pactific Islander Hispanic/Latino(a) Native American White Other Don't know

12. What drugs are they likely to have used? (Select all that apply)

Heroin Pain Pills Cocaine Fentanyl Benzos Alcohol Amphetamines/Meth Methadone Other Don't know

13. What kind of place did the overdose happen at?

14. How do you know the person who overdosed?

15. Has this person had an opioid overdose in the past?

Yes No Don't know

16. Do you need a replacement kit?

Yes No

16. If you need a replacement kit, or have another question, please leave your phone number or email address below and a GO Health staff member will contact you.

In addition to requesting a replacement kit from GO Health, you can use the Text-for-Naloxone line. To get a free naloxone kit, text KIT to 877-535-2461 to have naloxone mailed to the address you provide.

Naloxone is also available for pickup today at all pharmacies in New York State without a prescription. If you have prescription coverage through your health insurance, the Naloxone Copay Assistance Program will cover your copay up to $40. No enrollment is needed.