Indiana Naloxone Request and Report

Naloxone available through new partnership with the State of Indiana

Naloxone is a critical tool for individuals, families, first responders and communities to help reduce opioid overdose deaths. Due to the COVID-19 pandemic, local health departments registered with the Indiana State Department of Health as entities to dispense naloxone are experiencing limited access to resources. The State’s partnership with Overdose Lifeline, Inc. allows local health departments to devote their resources to the COVID-19 public health emergency. Read full Press Release from May 18, 2020.

In context of this grant, there are some distribution restrictions and a requirement to report use through an online form. We do our best to respond to all requests within 48 hours.

For naloxone box locations and distribution centers click here.

Naloxone & Fentanyl Test Strips Request

Fill Out Request Form

Please note this service is for Indiana residents only. Requests for Naloxone outside of the state of Indiana are not able to be fulfilled.

Please choose what best describes you: *

Individual
Organization/Agency
Distributor
HRSO Team
NaloxBox Monitor
Vending Machine Monitor
School
Other

¹ Individuals: Requesting naloxone or fentanyl test strips (FTS) to carry on yourself, for a family member, or a friend or in the event you encounter a person overdosing (this does not include formal organizations)

² Organization/Agency: Requesting naloxone or fentanyl test strips (FTS) as an organization to provide to staff, law enforcement officers, or would like to provide naloxone to the public in your community. Please choose Organization/Agency if you are requesting on behalf of a ‘work type’ scenario.

Organization Naloxone Request

Are you a first responder or representative from a first responder organization? *

Please select which first responder group you belong to: *

Name of Agency/Organization: *

In what county is your organization located? *

Your Name: *

First

Last

How will your organization distribute the kits received from ODL?

Pass through (kits given to other organizations)
Direct distribution (kits given directly to individuals)

If your organization distributes as a pass through and directly, please complete separate requests for each type of distribution.

Please describe the type of pass through:

Staff
First responders in community
School nurses
Probation officers
Clients

Individual Naloxone Request

Completion of this document will serve as evidence of overdose response training and therefore enable the individual to receive naloxone. Complete this document ONLY after completion of the overdose response training.

Is this your first time requesting naloxone? *

Please go to the Lay Responder Naloxone Training page and watch the video before proceeding.

Training confirmation *

I confirm that I watched the Lay Responder Naloxone Training and I understand how to respond to an opioid overdose using naloxone.

Training date: *

Indicate the approximate date you received Naloxone Training

County of training: *

Please select the training that your received:

Abbreviated (5-15min, can include in person training or a short training video)
Extended (45min-1hr, can include a class or be part of a course)

Please select the choice that best matches the type of training you received

Individual/Organization from which you obtained your training: *

Have you ever used naloxone? *

Yes
No
Not sure

Have you ever witnessed an overdose? *

Yes
No
Not sure

Is this your first time requesting naloxone from ODL? *

Are you interested in receiving intranasal naloxone (NARCAN)? *

Number of NARCAN kits you would like to request: *

Are you interested in receiving Intramuscular Naloxone? *

IM confirmation

I confirm that I am aware that intramuscular kits include 2 vials of naloxone, new syringes, and instructions for use.

Number of Intramuscular Naloxone kits you would like to request: *

Are you interested in receiving Fentanyl Test Strips? *

Number of Fentanyl Test Strips you would like to request: *

Please select who you are requesting the kit(s) for? (Select all that apply) *

Friend
Partner
Client
Family Member
Community
Self
Other
Prefer to not answer

Please select who you are requesting Narcan kit(s) for? (other)

Please select your gender: *

Female
Male
Non-binary
Trans man
Trans woman
Prefer to not answer
Other

Please select your gender (other):

What is your race or ethnicity? *

American Indian/Alaskan Native
Asian
Black/African American
Native Hawaiian/Pacific Islander
Hispanic or Latino
White
Two or more races
Other
Unknown

Please describe your race:

Age: *

County of residence: *

What option best describes you? *

Individual/Family Member
Community Member
Business Owner
Health Professional
Addictions Professional
Educator/School

Please indicate the best way to contact you regarding your request/shipment: (select all that apply) *

E-mail
Phone

Phone: *

Email: *

Should Overdose Lifeline address these under a specific name? *

Overdose Lifeline strives to maintain your confidentiality as much as possible. You may choose to have the package placed under your name, or another’s; however, if you wish to maintain your privacy by omitting a name – we will address the package to “Current Resident.”

Recipient Name:

Overdose Lifeline will move forward with shipping your request to "Current Resident"

Shipping address: *

Address Line 1

Address Line 2

City

State

Zip Code

*note we can only ship naloxone within Indiana

Newsletter Sign-Up

Yes, please add me to the mailing list

Additional comments:

Naloxone Reporting

Fill Out Overdose Reversal Reporting Form

Overdose Reversal Reporting

The information provided through this form is solely viewed by ODL staff. The only information shared by Overdose Lifeline is the total number of overdose reversal reports that are submitted each month.

What option best describes you? *

Individual
First Responder
Organization/Agency (Non-First Responder)

Have you participated in the Recovery Capital Index? *

Please select which first responder group you belong to: *

First Responder: *

If other please specify

Name of Organization/Agency: *

County Narcan was used in: *

City/Town Narcan was used in: *

If Narcan was not used in a city or town, please provide the closest city or town.

Reporting Period - BEGIN DATE *

Reporting Period - END DATE *

First Responder and Organization/Agency Reporting

Please complete the following information for the reporting time period. Instance = the number of individuals who received naloxone. Example: If two individuals received naloxone from your department during the reporting time period, this would equate to "2 instances of naloxone use". If one of the two individuals required "2 doses" of naloxone, it would still be "2 instances of naloxone use". And you would record a "1" in the "Number of instances requiring one (1) dose" and record a "1" in the Number of instances requiring two (2) doses. Each number field requires an entry. Enter a zero (0) in any field where there wasn't a count for the reporting time period.

Number of instances naloxone was used: *

Instances that naloxone administration resulted in a life saved: *

Instances where the individual became combative after receiving naloxone: *

Instances where I had administered naloxone to the same individual in the past: *

Number instances requiring one (1) dose: *

Number instances requiring two (2) doses: *

Number instances requiring more than two (2) doses: *

What occurred after naloxone administration

(add zero in field if none)

Hospital transport - # instances *

Treatment referrals - # instances *

Jail transport - # instances *

Overdose Lifeline would ask you to consider treatment as an alternative to jail for overdose victims.

Gender

(add zero in field if none)

# Male *

# Female *

#Trans Man *

#Trans Woman *

#Non-Binary *

#Other *

Age

(add zero in field if none)

Under 15 *

15-24 *

25-34 *

35-44 *

45-54 *

55-64 *

65+ *

Race

(add zero in field if none)

# of American Indian/Alaskan Native *

# of Asian *

# of Black/African American *

# of Native Hawaiian/Pacific Islander *

# of Hispanic or Latino *

# of White *

# of Other *

# of Unknown *

Location/Place of Administration

(add zero in field if none)

# Residence (Private house or Apartment) *

# Hotel/Motel *

# Public Space *

# Business (other than Hotel/Motel) *

# Vehicle *

# Other *

Individual Overdose Reporting

Date of Overdose: *

Please select the approximate date that the overdose occurred

Who overdosed? *

Friend
Partner
Client
Family Member
Stranger
Self
Student
Other:

Who overdosed? (other) *

Please describe who overdosed

What was their age? *

Please indicate the approximate age the person who overdosed

What was their gender? *

Female
Male
Non-binary
Trans man
Trans woman
Unknown
Other:

Please describe their gender:

What was their race or ethnicity?

American Indian/Alaskan Native
Asian
Black/African American
Native Hawaiian/Pacific Islander
Hispanic or Latino
White
Two or more races
Other
Unknown

Please describe their race:

What setting did it occur in? *

Private house/apartment
Public park
Public bathroom
Affordable housing/Shelter
School
Other

What setting did it occur in? (other) *

Please describe the setting in which the overdose occurred

How many doses of naloxone were administered? *

What was the result of this person's overdose? *

They woke up without any help
They woke up because of my help
Don’t Know
Paramedics came and revived the person
Paramedics came and I don't know what happened next
They died
Other:

What was the result of this person's overdose? (other) *

Please describe what happened as a result of this overdose

Additional Comments

Fill Out Distributor Reporting Form

Distributor Reporting

Organization Reporting *

Please specify the organization distributing the Naloxone.

County of Organization Reporting *

Date of Distribution *

Number of Kits Distributed *

Type of Distribution *

Direct
Pass-through

Direct Distribution – Naloxone was provided directly to an individual.
Pass-through Distribution – Naloxone was provided to another organization for distribution to individuals.

Name of Receiving Organization *

Please specify the organization receiving the Naloxone.

Age (add zero in field if none)

Under 15 - # instances *

15-24 - # instances *

25-34 - # instances *

35-44 - # instances *

45-54 - # instances *

55-64 - # instances *

65+ - # instances *

Gender (add zero in field if none)

# of Male *

# of Female *

# of Transgender *

# of Unknown *

Race (add zero in field if none)

# of American Indian/Alaskan Native *

# of Asian *

# of Black/African American *

# of Hispanic/Latino *

# of Native Hawaiian/Pacific Islander *

# of White *

# of Other *

# of Unknown *

NaloxBox

Fill Out NaloxBox Report

NaloxBox Report

Organization / Name *

Email *

NaloxBox location address *

Address Line 1

Address Line 2

City

State

Zip Code

Report from (Date): *

Report to (Date): *

Number of kits taken out in this period: *

Questions, comments or concerns:

Newsletter Sign-Up

Yes, please add me to the mailing list

Fill Out NaloxBox Request

NaloxBox Request

Interested in Hosting a Naloxbox? Please fill out the form below:

Name *

First

Last

Organization *

County *

Requested NaloxBox intended address *

Address Line 1

Address Line 2

City

State

Zip Code

Phone Number *

Email *

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Indiana Naloxone Request and Report

Naloxone available through new partnership with the State of Indiana

Naloxone & Fentanyl Test Strips Request

Organization Naloxone Request

Individual Naloxone Request

Naloxone Reporting

Overdose Reversal Reporting

First Responder and Organization/Agency Reporting

What occurred after naloxone administration

Gender

Age

Race

Location/Place of Administration

Individual Overdose Reporting

Distributor Reporting

Age (add zero in field if none)

Gender (add zero in field if none)

Race (add zero in field if none)

NaloxBox

NaloxBox Report

NaloxBox Request

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