Report and Request FREE Naloxone Here

ISDH First Responder Report

Department/Agency Name
Please select your county from the drop down list. If you cover more than one county please make a notation in "Additional comments"

Reporting data

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.

What occurred after naloxone administration

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

Gender (add zero in field if none)

Age (add zero in field if none)

Race (add zero in field if none)

Location/Place of Administration (add zero in field if none)

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