Opioid Overdose Incident Report Form

If you’ve responded to an opioid overdose using the naloxone sent to you by our site 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 naloxone@nextdistro.org if you have any questions

* If you are reporting an overdose in NYC and request more naloxone, your information will be shared with NYCDOH so they can mail you a refill kit.