Naloxone program reporting form Question Title * Organization name (Required.) Question Title * Reporting month (Required.) Question Title * Name of person reporting (Required.) Question Title * Phone number (Required.) Question Title * Email address (Required.) Question Title * Key outcomes for the month(All fields required) (Required.) Number of individuals trained to administer Naloxone (clients, friends and/or family) Number of Naloxone kits distributed to individuals (clients, friends and/or family) Number of expired Naloxone kits Question Title * Number of individuals who reported administering or receiving Naloxone, including how many doses were given per administration 1 dose 2 doses 3 doses 4 doses 5 doses Question Title * Number of times that 911 was called when Naloxone was administered (Required.) Question Title * Please provide any additional information that you feel is pertinent for the ministry to know about, including anecdotal trends and reports. Done
