Provider Incident Reporting

When reporting overdoses and/or life threatening events please be as detailed as possible including only factual informational.

Company

First Name

Last Name

Address of Incident

Date of Incident

Approxiate Time of Incident

Describe the Incident

What actions were performed, i.e. CPR, Narcan, 911, Etc?

What were this person’s “drug of choice”, if applicable?

Were there any pertinent behaviors prior to the incident or overdose that you can recall? What were those behaviors?

If called, how soon were emergency responders called and how long did it take them to arrive?

Was anyone notified other than emergency responders?

What has been or will be done to assess and address the community in the aftermath?

Gender of Client, if applicable

Male

Female

Non-Binary

Age

What State did they come from, if non-resident?

How long have they lived in FL, if non-resident?

Why did they come to FL, if non-resident?

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