Overdose Reporting Form

We are collecting information through this form to understand overdoses and negative drug reactions in our community. This information will allow us to identify if there is a tainted or potent drug supply or an increase in overdoses so that we can respond and reduce drug-related deaths or harms. Please provide as much information as possible. If your client does not feel comfortable answering a question, or you didn’t get the chance to ask them some questions, fill in as much information as you know. In a situation where more than one person had an overdose or negative drug reaction, please submit a separate form for each person. If you have any questions about this form, please contact John Mitchell at john.mitchell@healthunit.ca or 705-474-1400 ext 5368.

1. Name of the person completing this form:

2. Organization/agency of the service provider completing this form:

Other (if you chose 'other' above, specify here):

3. What is the age of the person who had a negative reaction or overdose? If you don't know the age of the person please enter an approximate age.

4. Is this a known age, or an approximate age?

Known age

Approximate age

5. What is the gender of the person?

Male

Female

Unknown

Other (please specify in the text box below)

Other (if you chose 'other' above, specify here):

6. Date of incident. Please select your best estimate if you don't know the exact date.

7. Is this the exact date of the incident, or is it an estimated date?

This is the exact date

This is an estimated date

8. Time of incident (e.g. 14:00). Please enter your best estimate if you don't know the exact time.

9. In what town, township or First Nation did the incident happen?

10. If the incident happened in North Bay, what neighbourhood did it happen in?

Other (If you chose 'other' above, specify here):

12. Was 911 called?

Yes

No

I don't know

13. If 911 was not called, why not?

Concerns about Police

Naloxone revived person

Not able to

Person did not want to

Transported to hospital by bystander

Unknown

14. Was the person taken to a hospital?

Yes, by ambulance

Yes, but not by ambulance

No

I don't know

15. Was naloxone given to the person?

Yes, one dose

Yes, two doses

Yes, three or more doses

Yes, but dose unknown

No

I don't know

16. Did the person survive the incident?

Yes

No

I don't know

17. Is there anything else you would like to add? Please do not include any identifying information, including names.

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Overdose Reporting Form