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INDIANA REQUESTS & REPORTS
Naloxone Available Through New Partnership with State of Indiana
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FENTANYL TESTING STRIPS & NALOXONE REQUEST
First & Last Name
Narcan or Fentanyl Strips?
How Many Doses?
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Aaron's Law
I agree to view the training video or have received prior training
Training Video
SUBMIT
Your order has been placed. Thank you!
Email
Delivery or Pickup?
Street Address
Street Address Line 2
City
State
Zip code
Report
REPORT
OVERDOSE REVERSAL REPORTING
What Option Best Describes You:
Individual
First Responder
Organization / Agency
Have you ever participated in the Recovery Capital Index?
Yes
No
Who Overdosed?
Friend
Partner
Client
Family Member
Stranger
Self
Student
Other
What was their age?
What was their gender?
Male
Female
Non-Binary
Trans-Man
Trans-Woman
Unknown
Other
What was their race or ethnicity?
American Indian / Alaska Native
Asian
Black / African American
Native Hawaiian / Pacific Islander
Hispanic or Latino
Two or more races
Unknown
Other
What setting did it occur in?
Private House / Apartment
Public Park
Public Bathroom
Affordable Housing / Shelter
School
Other
How many doses of Naloxone were administered?
What was the result of the ovedose?
They woke up without any help
They woke up because of my help
Paramedics came and revived the person
Paramedics came and I don't know what happened next
I do not know
They died
Other
Additional Comments:
SUBMIT REPORT
Thank you for your participation.
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