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Naloxone Reporting Form

As required by the Ontario Naloxone Program (ONP), please complete and submit the form below by the following deadlines:

Q1 (April to June) report: July 15
Q2 (July to Sept.) report: October 15
Q3 (Oct. to Dec.) report: January 15
Q4 (Jan. to Mar.) report: April 15

If you have no information to report, you are still required to complete and submit this quarterly reporting form.

Contact information:

Agency Name

Contact First Name

Contact Last Name

Phone Number

Email Address

Year

Number of individuals trained to administer naloxone (clients, friends and/or family)

Number of naloxone kits distributed to individuals (clients, friends and/or family)

Number of SINGLE refill nasal spray doses distributed to individuals (NOTE: Do NOT include doses reported in kits distributed above. NOTE: 1 refill box = 2 single doses.)

Do you have any information about drug trends in your community or a need for naloxone in your community that is not being filled?

Information is collected and used under the authority of the Health Protection and Promotion Act R.S.O. 1990 cH.7, s.5. This information is collected and used for the purposes of substance use prevention and harm reduction and reporting to the Ministry of Health. Questions about this collection and use of information should be addressed to Durham Region Health Department, Manager, Health Information, Privacy and Security at 605 Rossland Rd E., P.O. Box 730, ON, L1N 0B2, (905) 668-7711.