Naloxone Use Reporting Form

Last name

Overdose Reversal and Naloxone Use Reporting Form for the General Public in Champaign County

If you are a member of the general public and have used Naloxone (Narcan®) yourself to reverse an overdose in Champaign County, please complete this short form. If you work in law enforcement, fire or Emergency Medical Services (EMS), please do not fill out this form.

Do you work for law enforcement, Fire or Emergency Medical Services (EMS)? *

Yes No

Have you previously administered Naloxone (also known by the brand name Narcan®) to someone in Champaign County? *

Yes No

When did you administer it?

Date *

Time *

What was the address where you administered it (please provide the full address or as much detail as you can—street, city, zip code)? *

What type of location? *

Home/residence (house, apartment)

Other residence (school residence hall, hotel/motel, etc.)

Public building (church, school, etc.)

Public outdoor site (Street/park/vehicle)

What was the person’s age (if known)? *

What was the person’s gender? *

Male

Female

Transgender woman

Transgender man

Non-binary/gender queer

Unknown

Other

What was the person’s race? *

American Indian or Alaska Native

Asian

Black or African American

Native Hawaiian or Other Pacific Islander

White

What was the person’s ethnicity? *

Hispanic or Latino

Not Hispanic or Latino

Do you know what drug the person used? (If no, skip the next question) *

Yes

Was 911 called? *

Yes

Unknown

Were they taken to the hospital? *

Yes

Unknown

How many doses of Naloxone did you administer? *

Single dose (2mg IN or 0.4 mg IV)

Multiple doses (>2mg IN or >0.4mg IV)

Not sure

Did the person(s) survive? *

Yes

Unknown

Naloxone Use Reporting Form

Champaign Urbana Public Health District