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Required format:

PqHe9iLgKhEErAucMqEpKJG7HpBUffNXdaIxZyJZ9tc

Overdose Event Report Form

Returning?

A A A

All fatal and nonfatal drug overdose events are to be reported to public health within 24 hours. To report an overdose event, please complete the questions below and select "Submit." At the end of the survey, you will be given the option to enter your email address to receive a copy of your responses.

To report via fax, please visit this link, complete the questions on the form, then fax to the Chelan-Douglas Health District at 509-559-7778. If you would like to report by phone, please call 509-886-6400.

Questions? Please contact the CD-Epi team at Chelan-Douglas Health District at 509-886-6400 or email cd-epi@cdhd.wa.gov.

Date of Report Notification

* must provide value

M-D-Y

Type of Reporting Agency

* must provide value

Name of Reporting Agency

* must provide value

Name of Reporting Agency

* must provide value

If other is selected, please list agency name:

* must provide value

Name of Person Reporting

Reporting Agency Phone

Patient Last Name

Patient First Name

Patient DOB

M-D-Y

Patient Phone Number

Is the patient experiencing homelessness?

Yes

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Patient Address

City

County

Zip code

Age in Years

View equation

Age in years (if unknown, please give approximation)

Gender

Other

Unknown

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Race (check all that apply)

American Indian/Alaska Native

Asian

Native Hawaiian/Other Pacific Islander

Black/African American

White

Other

Unknown

Ethnicity

Hispanic or Latino

Non-Hispanic or Latino

Unknown

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Date of Overdose Event

* must provide value

M-D-Y

County

* must provide value

Location/Address of Encounter

Was Naloxone administered?

Yes

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Number of doses administered

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Did patient respond to Naloxone?

Yes

Unknown

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Drug types, if known:

Opioids, RX

Opioids, non-RX

Cocaine

Methamphetamine

Alcohol

Other

Unknown

If other is selected, please describe:

If opioids (non-RX) are selected, please describe:

Route of drug consumption

Inhaled

Oral

Unknown

Drug use paraphernalia present?

Yes

Unknown

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Types of paraphernalia

Needle

Pipe

Scale

Other

If other, please describe

Additional comments about overdose event:

Expand

Did the patient have a COWS scale of 5 or greater?
(COWS = Clinical Opiate Withdrawal Scale)

Yes

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Did you leave Naloxone with the patient?

Yes

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How many Naloxone kits did you leave behind?

Did you administer Buprenorphine to the patient?

Yes

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How many doses of Buprenorphine did you provide the patient?

reset

Did you connect the patient to recovery services? (ScalaNW or Washington Recovery Helpline)

Yes

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Was the patient transported to the hospital?

Yes

Unknown

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Hospital Name:

If not transported to hospital:

Not needed

Refused

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Hospital event details

Admit date

M-D-Y

Discharge date (if known)

M-D-Y

Did the overdose event result in death?

Yes

Unknown

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Date of Death

M-D-Y

Was the coroner notified?

Yes

Unknown

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Case Definition for Reportable Overdose:

An overdose should be reported if considered by the reporter to be life threatening, or in the case of a fatality to be due primarily to a drug overdose (OD). The report should occur regardless of the substance(s) thought to be responsible. This definition is not meant to include indirect effects of substance use such as the risk associated with driving while intoxicated.

Confidentiality and Follow-Up Considerations:

Your facility is being asked to report all drug overdoses (OD's) to Chelan-Douglas Health District (CDHD) rather than issuing a "Health Order" mandating this reporting as a notifiable condition. The opioid epidemic like any epidemic, is tracked over time by public health. In addition, although an OD is a medical condition resulting from drug poisoning, some who experience overdoses may have substance use disorders for which treatment can be offered. The opportunity to offer such help is a second important reason for making OD's notifiable. The Center for Alcohol & Drug Treatment of Wenatchee will receive these reports so that they can follow up with OD patients who may have a substance use disorder and want to pursue treatment. These procedures are adopted to ensure patient confidentiality and compliance with HIPAA and CFR 42.

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Install Date

Y-M-D H:M:S

Install Date (UTC)

Y-M-D H:M:S

Participant Timezone

Participant Code

Mark field as:

[Clear value]

Unknown (UNK)

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