I Used My Naloxone

Thank you for filling out this form. If you used naloxone on more than one occasion, please submit a separate form for each occasion.

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How would you describe your gender?
Which type of naloxone did you use?


Where did you use your naloxone?

How many doses of naloxone did you use on the person who overdosed?*
When you used naloxone on the person who overdosed, did anyone call 911?*
Did the person who overdosed survive?*
In what setting did the overdose happen?*

Remember to get a refill so you will be prepared if you need to reverse another overdose.


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