Opioid Overdose Incident Form

If you’ve responded to an opioid overdose using the naloxone sent to you by our site, our sister site naloxoneforall.org or an affiliate organization, filling out this opioid overdose incident form is a necessity. Your responses will help us illustrate the importance of online and mail-based naloxone distribution. It is also the first step in mailing you a refill.

  • Your name is not required.

  • If you responded to more than one overdose (more than one person, date, or location) please fill out one form for each occurrence.

Please reach out to jamie@nextdistro.org if you have any questions

If you're not sure you can put the month/year.
Did the person who experienced the overdose... *
Do you know if the person who overdosed had used anything else?
Check all that apply, not required
If you answered "Yes" that someone else gave naloxone for the same overdose, were they...
Check all that apply, not required
If so, please describe.
We will contact you to confirm your address. Please look for our message.
Alternately, please call 917-828-0293. If we don't pick up right away, leave a message and someone will call you back as soon as possible.