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Naloxone Post-Administration Survey

Naloxone Administration Reporting Form

Thank you in advance for completing this form. The form is to be completed after you have responded to an incident that required the use of naloxone (Narcan®). The information will be used by the Southern Nevada Health District to help improve overdose prevention programs in our community.  All of the responses will be kept confidential and will be used only for aggregate statistical analysis.   

This survey will take an estimated time of 3 minutes to complete.

Don’t forget to get a refill of naloxone for your kit!
2. Location type? *This question is required.
3. Naloxone was used due to suspected: *This question is required.
This question requires a valid date format of MM/DD/YYYY.
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7. Gender of the individual who overdosed? *This question is required.
8. Race/ethnicity of the individual who overdosed? *This question is required.
9.

Overdose signs/symptoms exhibited?

*This question is required.
10. Did the individual who overdosed survive? *This question is required.
11. Was the individual referred to a substance use treatment facility/ Given information on substance use treatment? *This question is required.
Thank you for taking the survey! Click "Next" to submit the survey.
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