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Overdose reporting tool

Question Title

WHEN: Date of Incident

Date

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WHERE: Location of incident

Question Title

WHERE: Town/City or Township (Required.)

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WHAT: Occurred (check all that apply)

OD fatal

OD non-fatal

Tainted drugs suspected

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In the last 4 weeks did the individual attend any of the following (select any that apply):

Inpatient Detox

Community-Based Detox

BGH Concurrent Disorders Stabilization Unit

Royal Ottawa Acute Stabilization Unit

28 day or less Rehab

Long-Term Inpatient/Outpatient Rehab

Emergency Room Visit

Incarceration

Unknown

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Drug Format (pills, patches, powder, etc.)

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Suspected drug(s) involved (brief-description)

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Was 911 called?

Yes

Unknown

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Was Naloxone administered?

Yes

Unknown

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How much naloxone was used?

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If we have further questions, may we contact you?

Yes (Please provide your preferred contact information)

Personal Health and Information Protection Act (PHIPA)
This information is being collected under the authority of the Personal Health and Information Protection Act (PHIPA) and will be kept confidential and anonymous. If you have any questions please call us at 1-800-660-5853 and ask for Harm Reduction.

Overdose reporting tool

Question Title

* WHEN: Date of Incident

Question Title

* WHERE: Location of incident

Question Title

* WHERE: Town/City or Township (Required.)

Question Title

* WHAT: Occurred (check all that apply)

Question Title

* In the last 4 weeks did the individual attend any of the following (select any that apply):

Question Title

* Drug Format (pills, patches, powder, etc.)

Question Title

* Suspected drug(s) involved (brief-description)

Question Title

* Was 911 called?

Question Title

* Was Naloxone administered?

Question Title

* How much naloxone was used?

Question Title

* If we have further questions, may we contact you?

WHEN: Date of Incident

WHERE: Location of incident

WHERE: Town/City or Township (Required.)

WHAT: Occurred (check all that apply)

In the last 4 weeks did the individual attend any of the following (select any that apply):

Drug Format (pills, patches, powder, etc.)

Suspected drug(s) involved (brief-description)

Was 911 called?

Was Naloxone administered?

How much naloxone was used?

If we have further questions, may we contact you?