Illinois Saves Overdose

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

Unknown

Naloxone type*

Nasal

Muscle injection

Dosage needed* (?)

Was there a 911 call made?*

Yes

Unknown

Was the person conscious before naloxone was used?

Yes

Unknown

About the Person

Gender*

Male

Female

Transgender

Unknown

Age*

Race and Ethnicity*

American Indian

Asian

Black or African American

Hispanic or Latinx

Native Hawaiian or Pacific Islander

White

More Than One Race and Ethnicity

Unknown

Notes (optional)

Illinois Saves Overdose

Overdose Administration Form - Bystander