Date and time of the overdose event:
Now M-D-Y H:M M-D-Y H:M
What is your relationship to the person who overdosed?
Emergency Responder
Parent
Partner/ Spouse
Other family member (non-parent, non-partner)
Friend
Clinician/ Provider
Stranger
Self
Other
Test/demo (for training purposes only)**
Please specify "other" relationship:
13th Judicial Circuit Court Marshall's Office Adair County Sheriff's Office Affton Fire Protection District American Medical Response-Independence Andrew County Sheriff's Department Appleton City Police Department Arch City Defenders Archie Police Department Armstrong Fire Protection District Ash Grove Police Department Ashland Police Department Atchison County Sheriff's Department Atchison Holt Ambulance District Audrain County Health Department Aurora Police Department Ava Police Department Ballwin Police Department Barton County Sheriff's Office Bates City Police Department Bates County Sheriff's Department Battlefield Police Department Bel-Nor Police Department Bellefontaine Neighbors Police Belton Police Department Berkeley Fire Department Berkeley Police Department Bernie Fire Department Bernie Police Department Bertrand Police Department Big River Ambulance District Bismarck Fire Protection District Bland Police Department Bloomfield Department of Public Safety Bloomfield Police Department Blue Springs Police Department Blue Springs Department of Public Safety Blue Spring School Department of Public Saftey Bikes Fire Protection District BNSF Railway Police Team Bolivar Police Department Bollinger County Sheriff's Department Boone Hospital EMS Boonville Fire Department Boonville Police Department Bourbon Fire Department Bowling Green Police Department Bradleyville Fire Department Branson Police Department Branson West Police Department Brentwood Police Department Bridgeton Police Department Brookfield Police Department Brookline Fire Department Buchanan County Sheriff's Office Buckner Police Department Buffalo Police Department Bunker Police Department Butler County Alternative Services Program Butler County EMS Butler County Emergency Management Butler County Sheriff's Department Byrnes Mill Police Department Cabool Police Department Caldwell County Detention Center Callaway County Ambulance District Caldonia Fire Protection District California Police Department Calverton Park Police Department Camden County Sheriff's Department Camdenton Police Department Campell Police Department Canton Police Department Cape Girardeau Police Department Cape Girardeau Sheriff's Department Cape Girardeau County Sheriff's Office Cardwell Fire Department Carl Junction Police Department Carroll County Ambulance District Carroll County Sheriff's Department Carter County Sheriff's Department Carterville Police Department Caruthersville Fire Department Cass County Sheriff's Office Cassvile Fire Protection District Cassville Police Department Cedar Creek Fire Department Cedar Hill Fire Protection District Center Police Department Central Crossing Fire Protection District Central Jackson County Ambulance District Central Jackson County Fire Protection District Central Taney County Fire Protection District Centralia Police Department Chadwick Rural Fire Protection District Chariton County Ambulance District Chariton County Sheriff's Department Charleston MO Department of Public Safety Cherokee Pass Fire Department Chesterfield Police Department Chillicothe Fire Department Christian County Sheriff's Office City of Cape Girardeau Fire Department City of Kirksville Police and Fire Department City of Macon City Museum of St. Louis Security City of North Kansas City City of Rolla Fire and Rescue Department City of Rolla Police Department City of St. Charles Fire Department Clarkton Police Department Clay County Sheriff's Department Clever Police Department Clinton County Sheriff's Department Clinton Fire Department Cole County Emergency Medical Services Cole County Sheriff's Department Concordia Police Department Collins Fire Columbia Police Department Cooper County Sheriff's Office Cottleville Police Department Country Club Hills Police Department Cox Health Emergency Medical Services Crawford County Road District #2 Crawford County Sheriff's Department Crawford County Sheriff's Office Crestwood Police Department Creve Coeur Police Department Crocker Police Department Crystal Lakes Police Department Cuba Fire Department Cuba Police Department Curryville Fire Protection District Curryville Police Department Daviess County Sheriff's Department Dawn First Responders/ Fire Department Department of Homeland Security Desloge Police Department Des Peres Department of Public Safety Dent County Fire Protection District Dent County Sheriff's Office Dexter Police Department Diamond Police Department Dixon Police Department Doe Run Fire Protection District Doniphan Police Department Doolittle Rural Fire Protection District Dora Fire and Rescue Drexel Police Department Drexel Volunteer Fire Department Drury University Law Enforcement Academy Duenweg Police Department Dunklin County Juvenile Officers Dunklin County Sheriff's Department Dunnegan Critical Care Unit Stockton Ebenezer Protection District Eagle Rock Golden-Mano Fire Protection District East Prairie Police Department Eastern Douglas County Volunteer Fire Department Edgerton Police Academy Eldon Fire Department El Dorado Springs Police Department Ellsinore Police Department Eureka Police Department Excelsior Springs Fire Department Exeter Fire Protection District Fair Grove Police Department Fair Play Police Department Fayette Police Department Ferguson Police Department Florissant Police Department Fordland Police Department Forsyth Fire Department Forsyth Police Department Franklin County Sheriff's Department Fredericktown Police Department Fredericktown Fire Department Frontenac Police Department Fruitland Area Fire Protection District Garden City Ambulance Service Garden City Police Department Gentry County Sheriff's Office Gerald Police Department Gerald Rosebud Fire Protection District Gideon Police Department Gladstone Police Department Glasgow Fire and Rescue Department Glasgow Police Department Golden Valley Memorial Hosp EMS Goose Creek Lake Fire Department Gower Police Department Grain Valley Police Department Grandview Police Department Greene County Sheriff's Office Greenfield Police Department Greenwood Police Department Hallsville Police Department Hamilton Police Department Hannibal La-Grange University Department of Public Safety Hardin Police Department Harrison County/NTA Ambulance District Harrisonville Police Department Hayti Police Department Hazelwood Fire Department Hazelwood Police Department Heart of America Forensics Laboratory Herman Police Department Hickory County Sheriff's Department Higginsville EMS High Ridge Fire Protection District Hillsboro Fire Department Hillsdale Police Department Holden Police Department Hollister Police Department Hornersville Police Department Howard County 911 Howard County Public Health Department Howard County Sheriff's Office Independence Police Department Indian Point Police Department Ironton City Hall Ironton Police Department Iron County Ambulance District Iron County Sheriff's Office Iron Mountain Lake Police Department Jackson County Drug Task Force Jackson City Fire Department Jackson County Sheriff's Office Jackson Police Department Jamestown Police Department Jasper County Sheriff's Department Jasper Fire Protection District Jasper Police Department Jasper Volunteer Fire Jefferson City Fire Department Jefferson City Police Department Jefferson County Law Enforcement Academy Jefferson County Sheriff's Department Joachim Plattin Ambulance District Johnson County Emergency Management Agency Johnson County Sheriff's Office Jonesburg Police Department Joplin Fire Department Joplin Police Department Kahoka Police Department Kansas City Postal Inspector Kansas City Police Department Kansas City Fire Department Kearney Fire & Rescue Protection District Kearney Police Department Kennett Fire Department Kennett Police Department Kimberling City Police Department Kirkwood Police Department Knob Noster Fire Department Knob Noster Police Department Laclede County Sheriff's Office La Grange Police Department La Plata Community Fire Protection District Lafayette County Drug Task Force Lafayette County Sheriff's Office Lake Lotawana Police Department Lake of the Ozark's Police Department Lake St. Louis Police Department Lakeshire Police Department Lakeview Heights Fire Protection District Lake Winnebago Police Department Lathrop Fire Department Lathrop Police Department Lawrence County Sheriff's Department Lawson Police Department Leadington Police Department Lebanon City Fire Department Lebanon Police Department Lee Summit Fire Department Lee's Summit Police Department Lexington Fire and Rescue Lincoln County Sheriff's Department Lincoln Police Department Linn County Ambulance District Linn Police Department Logan-Rogersville School Police Department Lone Jack Police Department Lowry City Fire Department Lowry City Police Department Macon County Ambulance District Macon County Fire Department Macon County Sheriff's Office Madison County Sheriff's Department Malden Fire Department Manchester Police Department Mansfield Police Department Maplewood Police Department Marceline Fire Department Marceline Police Department Maries County Sheriff's Department Marion County Ambulance District Marion County Sheriff's Department Marshall Police Department Marshfield Fire Department Marthasville Police Department Maryville Police Department Matthews Police Department McDonald County Sheriff's Department MCCKC Public Safety Institute Medicine Shoppe Pharmacy Mercy Emergency Medical Services Merriam Woods Police Department Metro Emergency Transport System Mid County Fire Protection District Mid Missouri Drug Taskforce Mid MO Ambulance District Milan Police Department Miller County Sheriff Department Miller Police Department Miner Fire Department Miner Police Department Mississippi County Ambulance District Mississippi County Sheriff's Department Missouri Capital Police Missouri Court of Appeals - Eastern District Missouri Department of Conservation Missouri Department of Natural Resources Missouri Department of Social Services Missouri Department of Transportation Missouri Gaming Commission Missouri Narcotics Officer Association Missouri Park Rangers Missouri Probation and Parole Missouri State Highway Patrol Missouri State Park Rangers Missouri S&T University Police Department Missouri Western State Univ. Police Department Moberly Police Department Moline Acres Police Department Monett Fire Department Monett Police Department Monroe City Police Department Monroe City Police Department Monroe City Sheriff's Department Montgomery County Sheriff's Office Moody Fire Department Moody Volunteer Fire Department Moreau Fire Protection District Morgan County Sheriff 's Department Moscow Mills Police Department MSU Public Safety Training Center Multi-County Narcotics and Violent Crimes Enforcement Unit Myrtle Fire Department National Park Service Nevada Fire Department Nevada Police Department NEMO CIT Newbug Police Department New Franklin Police Department New Haven Police Department New London Fire Department New Madrid Police and Fire Department Newton County Ambulance District Niangua Fire Department Nixa School Police Norborne Police Department Normandy Police Department North Bolinger County Fire and Rescue North County Police Cooperative North Jefferson Ambulance District Northwoods Police Department Office of the Inspector General, GSA Odessa Police Department Oregon County Sheriff's Department Orrick Police Department Osage Ambulance District Osage Beach Fire Protection District Osage Beach Police Department Osage County Sheriff Department Osceola Police Department Otterville Rural Fire Protection District Overland Police Department Owensville Volunteer Fire Department Ozark County Sheriff's Department Ozark Fire Protection District Ozark National Scenic Riverways Ozark Police Department Ozarks Technical Community College Simulation Center Pacific Police Department Park Hills Police Department Parkway South High School Pemiscot County Sheriff's Office Perry County Ambulance District Perry County Sheriff's Department Perryville Police Department Pettis County Sherriff's Office Piedmont Police Department Pike County Memorial Hospital EMS Pilot Knob Police Department Pineville Police Department Platte Woods Police Department Plattsburg Police Department Pleasant Hill Police Department Pleasant Hope Fire Protection District Poplar Bluff Fire Department Poplar Bluff Police Department Potosi Police Department Pulaski County Sheriff's Department Purdy Police Department Puxico Police Department Randolph County Sheriff's Office Raymore Police Department Redings Mill Fire Protection District Reeds Spring Police Department Reynolds County Ambulance District Rich Hill Police Department Richland Police Department Richwoods Fire Protection District Ripley County Ambulance District Ripley County Sheriff's Department Riverside Police Department Robertson Fire Rockaway Beach Police Department Rolla Police Department Rosebud Police Department Salem Police Department Saline County Jail Salisbury Police Department Salt River Ambulance District Sarcoxie Fire Department Schuyler County Sheriff Department Scott City Fire Department Scott City Police Department Scott County Rural Fire Department Scott County Sheriff's Department Sedalia Police Department Seligman Police Department SEMO Drug Task Force Senath Police Department Seymour Police Department Shannon County First Responders Shrewsbury Police Department SLU Department of Public Safety Sikeston Police Department Sleeper Volunteer Fire Department Smithville Police Department Southeast Missouri State University Department of Public Safety Southwest City Police Department South Howell County Ambulance District Southern Boone County Fire Protection District Southern Stone County FPD Sparta Police Department Springfield Fire Department Springfield Police Department Strafford Fire Protection District Steele Police Department Steelville Police Department Stoddard County Sheriff's Office Stone County Sheriff's Department Stoutland Volunteer Fire Department Stover Police Department Strafford Police Department St. Ann Police Department St. Clair County Sheriff's Department St. Clair County Sheriff's Office St. Clair Fire Protection District St. Charles County Ambulance District St. Charles City Police Department St. Charles County Sheriff Department St. Charles Community College PD St. Francois County Ambulance District St. Francois County Sheriff's Department St. James City Police Department St. Joseph Police Department St. Louis City EMS St. Louis County Police Department St. Louis Health Department St. Louis Lambert Airport Police Department St. Louis Metropolitan Police Department St. Louis University Police Sugar Creek Fire and Police Department Sullivan Police Department Sunrise Beach Fire Protection District Squires Volunteer Fire Department Stockton Police Department Taney County Ambulance District Taney County Sheriff's Department Tecumseh Volunteer Fire Department Terre Du Lac Fire Department Thayer Police Department Town and Country Police Department Tri-County Fire Protection District Trimble Police Department Troy Fire Department Troy Police Department Truman University Police Department U.S. Probation and Parole Officers UMKC Police Department Union Police Department University of Missouri EMS University of Missouri-Kansas City Police Department University of Missouri Police Department University of Missouri St. Louis Police Department United States Postal Inspection Service Urban Rural Fire Department Van Buren Fire Department Velda City Police Department Vernon County Health Department Vernon County Sheriff's Office Versailles City Fire Department Versailles Rural Fire Protection Viburnum Police Department Vienna Fire Department Walnut Grove Police Department Wardell Fire and Rescue Warren County Ambulance District Warren County Sheriff's Office Warrensburg Police Department Warrenton Police Department Warrenton City Police Department Warrenton Fire District Warsaw Police Department Warson Woods Police Department Washington County Sheriff's Office Washington University Police Department Waynesville Rural Fire Protection District Webb City Fire Department Webb City Police Department Webster County Sheriff's Department Webster Groves Police Department Wellsville Police Department Wentzville Police Department West Overland Fire Protection District West Plains Police Department West STL County Police Department Westboro Volunteer Fire Department Western Taney County Fire Protection District 333333340922. Weston Police Department Wheaton Police Department Willard Police Department Willard School Police Department Willow City Fire Department Willow Springs Police Department Wolf Creek Fire Department Wood Heights Police Department Woodson Terrace Police Department Worth County Sheriff's Department Wright City Police Department Wright City Fire Department Zalma Fire Department Other Test Agency (**This is for demo/training purposes only)
Please specify "other" agency:
**Please confirm this is a demo entry and NOT a report of an actual overdose event. Click "Yes" if this entry is for training purposes only.
* must provide value
Yes
No
Is the individual a Missouri resident?
Yes
No
Homeless
Unsure
What is the individual's state of primary residence?
Illinois Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Unsure
In what county did the overdose occur?
Jackson County St. Charles County St. Louis City St. Louis County Adair County Andrew County Atchison County Audrain County Barry County Barton County Bates County Benton County Bollinger County Boone County Buchanan County Butler County Caldwell County Callaway County Camden County Cape Girardeau County Carroll County Carter County Cass County Cedar County Chariton County Christian County Clark County Clay County Clinton County Cole County Cooper County Crawford County Dade County Dallas County Daviess County DeKalb County Dent County Douglas County Dunklin County Franklin County Gasconade County Gentry County Greene County Grundy County Harrison County Henry County Hickory County Holt County Howard County Howell County Iron County Jasper County Jefferson County Johnson County Knox County Laclede County Lafayette County Lawrence County Lewis County Lincoln County Linn County Livingston County Macon County Madison County Maries County Marion County McDonald County Mercer County Miller County Mississippi County Moniteau County Monroe County Montgomery County Morgan County New Madrid County Newton County Nodaway County Oregon County Osage County Ozark County Pemiscot County Perry County Pettis County Phelps County Pike County Platte County Polk County Pulaski County Putnam County Ralls County Randolph County Ray County Reynolds County Ripley County Saline County Schuyler County Scotland County Scott County Shannon County Shelby County St. Clair County St. Francois County Ste. Genevieve County Stoddard County Stone County Sullivan County Taney County Texas County Vernon County Warren County Washington County Wayne County Webster County Worth County Wright County Unsure N/A
ZIP Code of overdose location:
A home/residence
A treatment facility
A public place
Other
Please specify the public place location:
Please specify the other location:
Under 18
18-24
25-44
45-64
65+
(If you are unsure, please give your best estimate)
Male
Female
Intersex
Unsure
Individual's race: (check all that apply)
(If uncertain, please select best guess AND "unsure")
Please specify other race:
Is the individual Hispanic?
(If uncertain, please select best guess AND "unsure")
Type of drugs involved: (check all that apply)
(If uncertain, please select best guess AND "unsure")
Please specify "other" drugs:
Was naloxone administered?
Yes
No
Unsure
Where was naloxone obtained?
Unsure; naloxone administered by someone else
Pharmacy
Treatment Program
Recover Community Center
Jail or Treatment court program
An Emergency Responder gave it out
Health Department / Local Public Health Agency
Better Family Life
Faith-based organization
The T STL
Other
Please specify which Recovery Community Center provided you with naloxone:
Missouri Network for Opiate Reform and Recovery
St. Louis Empowerment Center
Springfield Recovery Community Center
Healing House
Other
Please specify the pharmacy:
Please specify the treatment program (agency name):
Please specify the Recovery Community Center (agency name):
Please specify the jail or treatment court program:
Please specify health department / local public health agency
Adair Andrew Atchison Audrain Barry Barton Bates Benton Bollinger Boone Buchanan (St. Joseph Health Department) Butler Caldwell Callaway Camden Cape Girardeau Carroll Carter Cass Cedar Chariton Christian Clark Clay Clinton Cole Columbia-Boone Cooper Crawford Dade Dallas Daviess Dent Douglas Dunklin Franklin Gasconade Greene Grundy Harrison Henry Hickory Holt Howard Howell Independence Iron Jackson Jasper Jefferson Johnson Kansas City Knox Laclede Lafayette Lawrence Lewis Lincoln Linn Livingston Macon Madison Marion McDonald Mercer Miller Mississippi Moniteau Monroe Montgomery Morgan New Madrid Newton Nodaway Oregon Osage Ozark Pemiscot Perry Pettis Phelps/Maries Pike Platte Polk Pulaski Putnam Ralls Randolph Ray Reynolds Ripley Saint Charles Saint Clair Saint Francois Saint Louis Saint Louis City Sainte Genevieve Saline Schuyler Scotland Scott Shannon Shelby Stoddard Stone Sullivan Taney Texas Tri-County (Dekalb, Gentry, and Worth) Vernon Warren Washington Wayne Webster Wright
Naloxone administered by:
(Please select multiple responses, if more than one person administered naloxone)
Please specify "other" emergency responder:
Please specify who administered the naloxone:
What form of naloxone was administered?
(Select all that apply)
How many doses of AdaptPharma Narcan nasal spray were given?
1
2
3
4 +
Unsure
How many doses of Evzio auto-injector were given?
1
2
3
4 +
Unsure
How many doses of intranasal naloxone were given with vial and atomizer?
1
2
3
4 +
Unsure
How many doses of naloxone were given intravenously (IV)?
1
2
3
4 +
Unsure
How many doses of intramuscular naloxone were given with vial and syringe?
1
2
3
4 +
Unsure
Any opioid withdrawal symptoms post-naloxone administration? (check all that apply)
Please specify other symptoms:
Yes
No
Unsure
To the best of your knowledge, did the individual survive the overdose?
Yes
No
Unsure
Was the individual transported to the hospital?
Yes
No, escorted to treatment center
No, escorted to a residence
No, transported elsewhere
No, declined transport
No, transportation was not available/offered
Unsure
N/A, deceased at scene
Are you participating in the leave-behind (LBH) program for MORE?
Yes
No
What is the primary payer source for the individual who overdosed?
Private insurance
Self-pay/ no insurance
Medicaid
Medicare
Other government insurance
Unknown
How many naloxone kits were left behind?
Please specify the number of kits left behind.
To whom did you provide a naloxone kit (please, select all that apply)
Did the client consent to contacting an EPICC Coach?
Yes
No
Client was revived but not asked
Other/NA
Was an EPICC Coach contacted?
Yes
No
Did you provide the individual who overdosed or their family/friends with a treatment-related resource card?
Yes
No
Did you supply anyone at the scene with a Leave Behind Naloxone Kit?
* must provide value
Yes
No
Attention Emergency Responders:
According to the Missouri's Good Samaritan Law (RSMO 195.205, Effective August, 2017)
All police officers who respond to drug or alcohol overdose shall provide
appropriate treatment-related resources.
Did the individual who overdosed or his/her family receive a treatment-related resource card
Yes
No