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.
2. Organization/agency of the service provider completing this form:
4. Is this a known age, or an approximate age?
 
5. What is the gender of the person?
 
7. Is this the exact date of the incident, or is it an estimated date?
 
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?
11. What drugs were involved in the overdose/incident? (select all that apply)
 
12. Was 911 called?
 
13. If 911 was not called, why not?
 
14. Was the person taken to a hospital?
 
15. Was naloxone given to the person?
 
16. Did the person survive the incident?