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About Us
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Programs
Events
Kansas Opioid and Stimulant Conference
Leading Causes of Life 5K
Ways to Support
Resources
Substance Use Disorder Treatment FAQ
Begin Recovery
Request a Training
Prevention Resources & Toolkits
Client Resources
Support DCCCA
Improving Lives…Close to Home
Recovery Today Fund
Volunteer
Careers
Contact
Contact
Employee Log-In
Pay Bill
Donate
About Us
Our Team
About Us
Our Culture & Values
History
Locations
Annual Reports
Programs & Services
Programs
Events
Kansas Opioid and Stimulant Conference
Leading Causes of Life 5K
Ways to Support
Resources
Substance Use Disorder Treatment FAQ
Begin Recovery
Request a Training
Prevention Resources & Toolkits
Client Resources
Support DCCCA
Improving Lives…Close to Home
Recovery Today Fund
Volunteer
Careers
Contact
Contact
Employee Log-In
Pay Bill
Donate
Overdose Response
Program Type:
Community Based Services
Program Category:
Naloxone Program
Naloxone Leave Behind Overdose Response Form
Date of event:
(Required)
MM slash DD slash YYYY
Was this an overdose event?
(Required)
Yes
No
If not an overdose, please provide a description of the event.
(Required)
An example may include provided naloxone to an individual with known substance use disorder prior to overdose.
Approximate time of overdose event:
(Required)
Morning
Afternoon
Evening
What is your relationship with the person who overdosed?
(Required)
Emergency Responder
Parent, Partner/Spouse, Other Family Member
Friend
Clinician/Provider
Stranger
Self
Other
Is the individual a Kansas resident?
(Required)
Yes
No
Unhoused
Unsure
In what Kansas county did the overdose occur?
(Required)
Select
Allen
Anderson
Atchison
Barber
Barton
Bourbon
Brown
Butler
Chase
Chautauqua
Cherokee
Cheyenne
Clark
Clay
Cloud
Coffey
Comanche
Cowley
Crawford
Decatur
Dickinson
Doniphan
Douglas
Edwards
Elk
Ellis
Ellsworth
Finney
Ford
Franklin
Geary
Gove
Graham
Grant
Gray
Greeley
Greenwood
Hamilton
Harper
Harvey
Haskell
Hodgeman
Jackson
Jewell
Johnson
Kearny
Labette
Lane
Leavenworth
Lincoln
Linn
Logan
Lyon
Marion
Marshall
McPherson
Meade
Miami
Mitchell
Montgomery
Morris
Morton
Nemaha
Neosho
Ness
Norton
Osage
Osborne
Ottawa
Pawnee
Phillips
Pottawatomie
Pratt
Rawlins
Reno
Republic
Rice
Riley
Rooks
Rush
Russell
Saline
Scott
Sedgwick
Seward
Shawnee
Sheridan
Sherman
Smith
Stafford
Stanton
Stevens
Sumner
Thomas
Trego
Wabaunsee
Wallace
Washington
Wichita
Wilson
Woodson
Wyandotte
ZIP Code of overdose location:
(Required)
ZIP Code
Incident Location:
(Required)
Home/Residence
Treatment Facility
Public Place
Other
Individual's age:
(Required)
Under 18
18-24
25-44
45-64
65+
Unsure
Individual's gender:
(Required)
Male
Female
Transgender male / man
Transgender female / woman
Unsure
Individual's race: (check all that apply)
White
Black/African American
Asian
American Indian/Alaskan Native
Middle Eastern or North African
Native Hawaiian/Pacific Islander
Other
Unsure
Is the individual Hispanic?
(Required)
Yes
No
Unsure
Was naloxone administered?
(Required)
Yes
No
Unsure
To the best of your knowledge, did the individual survive the overdose?
(Required)
Yes
No
Unsure
Δ
