Illinois Saves Overdose

Overdose Administration Form - Bystander

If you are a friend, family member or outreach worker and have administered the medication naloxone, please complete the following fields to the best of your ability.

We prefer that you use your best guess to complete each field rather than leave blank and not answer. Please note your data is stored anonymously and securely. Thank you for all your efforts.

Location of Naloxone Administration

Administration County Location*

Closest Cross Streets

City*

ZIP Code

Site Type*

Home/Residence (includes house, apartment, and condominium)
Other Residence (School Residence Hall, Nursing Home, Military Base, Prison/Jail, Recovery Home, In-patient Treatment Facility, Hotel/Motel/SRO)
Public Building Site (Church, School, Courthouse, Library)
Business Site (Restaurant, Store/Mall, Train/Bus Station, Rest Stop/Gas Station – Includes Public Bathroom)
Public Outdoor Site (Street/Park/Lots/Vehicles/Public Transportation Platforms)
Unknown
Other (Please Specify)

Naloxone Administration - Condition of Person

Date Naloxone used*

Did the person survive?*

Yes
No
Unknown

Naloxone type*

Nasal
Muscle injection

Dosage needed* (?)

Was there a 911 call made?*

Yes
No
Unknown

Was the person conscious before naloxone was used?

Yes
No
Unknown

About the Person

Gender*

Male
Female
Transgender
Unknown

Age*

Race and Ethnicity*

Notes (optional)

Illinois Saves OD is funded by the Substance Abuse and Mental Health Services Administration through the Opioid State Targeted Response grant administered by the Illinois Department of Human Services, Division of Substance Use Prevention and Recovery. (TI-080231). | Contact us: mailto:DHS.DOPP.Coordinator@Illinois.gov