Report Anonymously

Filling out the below reversal report is fast, easy, and anonymous. Thank you in advance for taking a moment to share event basics.

    Q0: What state did the reversal occur in?

    OpiRescue does not support reversal reports in your state. Please use the OpiRescue app to record reversals.

    Q1: On what dates did the overdose happen?

    Q2: At about what time?

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    Q3: Street where it occurred?

    Q4: Nearest cross street?

    Q5: Was the person male, female, or other

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    Q6: What made you think this was an overdose?

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    Q7: What drugs had they taken? (only check the ones you are sure of)

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    Q8: Did you or anyone call 911?

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    Q9: Did you or anyone administer Naloxone?

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    Q10: Where did you get your kit?

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    Q11a: What type of naloxone?

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    Q11b: Which brand of nasal spray?

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    Q12: How many complete doses did you deliver?

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    Q13: What else did you do? (select all that apply)

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    Q14a: Did you use Fentanyl testing strips?

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    Q14b: What was the result of the Fentanyl test?

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    Q15: Did the person regain consciousness?

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    Q16: How long did it take?

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    Q17: Did the person survive?

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    Q18: Were there any side effects? (select all that apply)

    Select up to 3 from options (IF None +1 pick, ignore None):

    Q19: Did the person go to the hospital?

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    Q20: Are you a certified first responder (EMT, police, firefighter)?

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    Q21: Your name?

    Q22: Your state?

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    Q23: Your organization?

    Q24: What is your department number or identifier?

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