Report Naloxone Save

Did you use a Matt Adams Foundation Naloxone Kit?

Please Report Your Naloxone Save Below

First of all, if you are here. THANK YOU. You saved somebody’s someone, and a whole family an unimaginable amount of heartbreak on top of giving another human being a second chance at life. You’re a beautiful person and we are so grateful you got your hands on one of our kits.

Thank you for reporting your save. This helps us keep track of resources, where we need to put more effort for naloxone distribution, and helps us in gaining community and governmental support for this program.

And of course, please let us know if you need another naloxone kit <3

Please report your save below, not all question responses are required, so report what you can or choose to at your own discretion. Thank you!

Date

City

State

Was More Than One Naloxone Kit Used?

No, only one Naloxone kit was used
Yes, more than one Naloxone kit was used

Number of Kits Used (If More than One) *

Substances in System at Time of Overdose Reversal (Check all that apply)

Heroin
Cocaine
Fentanyl (Known)
Fentanyl (Suspected)
Oxycontin
Hydrocodone
Xanax/Other Benzodiazepines
MDMA or Ecstasy
Ketamine
Methamphetamine
Adderall/Other Prescription Stimulate
Alcohol
Other

Other Description

Was this from a Tainted Supply?

Yes, I suspect the supply was tainted
No, I do not expect that the supply was tainted

In other words, do you suspect that there anything in the substance that was unexpected? This is entirely confidential but useful so we can raise flags to the community of any tainted supply in the area.

Can we reach out to you about some details including when and in what city you/your acquaintance received the tainted supply? (If Applicable)

Yes
No
Not applicable

We may potentially put out a PSA post on local tainted drug supplies to our constituents so people are extra careful.

Contact Number

Age of Person(s) Who Received Naloxone (Estimates OK)

Any Details You Would Like to Share

Name

First

Last

*Not required - you may stay anonymous if you choose

Can we use your comments as a public save story?

Yes - You can share this story publicly
No - I'd prefer this story not be shared publicly

*These stories emphasize how important harm reduction and naloxone distribution programs are and how ordinary citizens can save someone's life if they are prepared and choose to act. Everyone knows the statistic, but we find people can really connect and empathize through stories. We can share anonymously if you want it shared that way as well.

Name