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Home
About
About MAP
Harm Reduction
Services
Naloxone & Overdose Prevention
Syringe Access
Drug User Led Education
Health Services for Drug Users
Calendar
Resources
General Resources
Maine Resources
Virtual Education
Merch
Donate
Contact Us
Participant Code with MAP
(First and last initial - first two letters of mom's first name - day of birth)
Today's Date
MM
DD
YYYY
Approx Date of Overdose
MM
DD
YYYY
Who overdosed?
Friend
Partner/spouse
Stranger/acquaintance
Family member
Client/program participant
I did
Other
Gender of the person who overdosed?
Female
Male
Nonbinary
Transgender
Other
What drugs had they taken? Only check those that you are sure of.
Fentanyl
Heroin
Methadone
Pharmaceutical opioids (Morphine, Percocet, Roxicodone, Oxycodone, Vicodin, etc.)
Buprenorphine (Suboxone, Subutex)
Benzos (Klonopin, Xanax, Ativan, Valium, Librium, etc.)
Cocaine/Crack
Alcohol
Methamphetamine
Spice
Other
What town did the overdose take place in?
What environment did the overdose happen in?
Private house/apartment
Public Park
Public Bathroom
Hotel room
Street/Alley
Camp
Car
Other
What did you do (or if reporting about your own overdose, what did the person do to revive you)?
Sternum Rub
Called 911
Rescue breathing
Gave Narcan
What else was done to try and revive the person?
What kind of narcan what used?
Injectable
Nasal
How many doses were used?
How long did it take for the narcan to work?
Less than 1 minute
1-3 minutes
3-5 minutes
More than 5 minutes
It didn't work (please write notes below about why)
Did the person that received the naloxone experience any negative side effects? What were they?
Did any of the following happen?
Arrest of overdosing person or witnesses/user of narcan
Harassment by police
Harassment by paramedics/fire department
Loss of access to resources (ex. kicked out of shelter, trespassing orders, loss of treatment or housing)
Please use this space to document anything unusual or interesting about the overdose, the reversal, good quotes/stories, problems putting the narcan together or using it, info about the drugs causing the overdose, any adverse reactions that the person had after getting narcaned, details about negative interactions with police/fire/ems, etc.
Do you want a refill of more naloxone?
*
Yes
No
What's the best way to get in touch with you for the refill?
Call
Text
E-mail
Enter phone number/email or N/A if no follow up desired
*
Thank you!
