Arkansas Naloxone Reporting Administration

Please complete the survey below.

Thank you!

Naloxone is an opioid reversal medication. Please enter all data as accurately as possible. If information is not available, please enter "unknown".

MM slash DD slash YYYY
Location(Required)
Who gave naloxone?(Required)
The first and last name of the individual who gave naloxone (optional)?
Outcome of Administration?(Required)
Please enter a number from 0 to 10.
Which substance was used?(Required)
Was this a suicide attempt?(Required)
Did the naloxone recipient seek medical care post-administration?(Required)
Age of naloxone recipient?(Required)
Gender of naloxone recipient?(Required)
Race of naloxone recipient?(Required)
Ethnicity of naloxone recipient?(Required)
This field is for validation purposes and should be left unchanged.