Law Enforcement Agency Partner Monthly Overdose Reversal Reporting Form

Please complete this form to the best of your abilities, based on organization records of overdose events and/or staff reporting. This form collects data on overdoses reversed by members of your agency only. We are asking these questions to gain a better understanding of the types and quantities of overdose encounters our partner agencies experience. If you do not have any overdose reversals to report for this month, please scroll to the bottom of the form and enter "No overdose reversals to report" in the Additional Information text box. If you encounter any issues or have any questions about this form, please contact Denise Holman at denise.holman@cookcountyhealth.org.

Which Law Enforcement Agency are you from?

Agencies are listed alphabetically - please type the name into the search bar at the top, or scroll to find the right option. If you do not see your agency on this list, please contact Denise Holman at denise.holman@cookcountyhealth.org.

Add

Date of Overdose Reversal

Please complete to the best of your abilities

Where did the overdose occur?

Please enter zip code if known, general neighborhood area if not

How many doses of naloxone were required to reverse the overdose?

If using intramuscular naloxone, please report the number of vials used total. If using intranasal naloxone (NARCAN), please report the number of spray kits used total (2 kits come in each box).

Any additional information you would like to share?

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