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OVERDOSE REPORT FORM To be sent to the Department of Public Health confidential fax number: 1 866 8678026 Details for use on reverse Identification of reporting individual Name:Function:Northern village:Telephone:Identification

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How to fill out overdose report form

01

Obtain the overdose report form from the appropriate authority or organization.

02

Fill in the details of the individual who experienced the overdose, including their name, age, and contact information.

03

Provide information about the overdose incident, including the date, time, and location it occurred.

04

Describe the substances involved in the overdose, as well as the quantity and any other pertinent details.

05

Include any relevant medical treatment given to the individual following the overdose.

06

Sign and date the form to certify its accuracy and completeness.

Who needs overdose report form?

01

Healthcare providers

02

Emergency responders

03

Public health agencies

04

Drug treatment facilities

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What is overdose report form?

The overdose report form is a document used to report instances of drug overdose.

Who is required to file overdose report form?

Healthcare providers and medical facilities are required to file overdose report forms.

How to fill out overdose report form?

The overdose report form must be completed with details of the overdose incident, including the date, time, location, and substances involved.

What is the purpose of overdose report form?

The purpose of the overdose report form is to track and monitor drug overdose incidents for public health and safety reasons.

What information must be reported on overdose report form?

The overdose report form must include information such as the name of the patient, type and amount of substances involved, and outcome of the overdose incident.

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