NONFATAL OVERDOSE REPORT
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required fields
County Where Nonfatal Overdose Occurred:
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Adair
Alfalfa
Atoka
Beaver
Beckham
Blaine
Bryan
Caddo
Canadian
Carter
Cherokee
Choctaw
Cimarron
Cleveland
Coal
Comanche
Cotton
Craig
Creek
Custer
Delaware
Dewey
Ellis
Garfield
Garvin
Grady
Grant
Greer
Harmon
Harper
Haskell
Hughes
Jackson
Jefferson
Johnston
Kay
Kingfisher
Kiowa
Latimer
Le Flore
Lincoln
Logan
Love
Major
Marshall
Mayes
McClain
McCurtain
McIntosh
Murray
Muskogee
Noble
Nowata
Okfuskee
Oklahoma
Okmulgee
Osage
Other
Ottawa
Pawnee
Payne
Pittsburg
Pontotoc
Pottawatomie
Pushmataha
Roger Mills
Rogers
Seminole
Sequoyah
Stephens
Texas
Tillman
Tulsa
Wagoner
Washington
Washita
Woods
Woodward
Date of Nonfatal Overdose:
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Age of Person That Overdosed:
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0
1
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100
Race of Person That Overdosed:
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Gender of Person That Overdosed:
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American Indian
Asia
Black
Hispanic
Other
Pacific Islander
White
Male
Female
Accidental, Suicide Attempt or Unknown:
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Was Naloxone/Narcan Administered:
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Accidental
Suicide Attempt
Unknown
Yes
No
Type of Controlled Substances Involved (You may select multiple times):
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Alprazolam
Amitriptyline
Ampehtamine
Buprenorphine
Carisoprodol
Citalopram
Clonazepam
Cocaine
Codeine
Diazepam
Ephedrine
Fentanyl
Heroin
Hydrocodone
Hydromorphone
Marijuana
Meperidine
Methadone
Methamphetamine
Methylphenidate
Morphine
Other
Oxycodone
Oxymorphone
Pentazocine
Phetermine
Promethazine
Propoxyphene
Tramadol
Triazolam
Zolpidem Tartrate
Method Individual Used to Obtain Controlled Substance(s):
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Prescription
Internet
Family Member
Friend
Street Dealer
Other
Unknown
OTC
Reporting Facility
Facility's Name:
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Address
City
State
Zip
Reporting Person's Name:
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Phone:
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email:
Comments: