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Community partners are to complete this form to report how many people were trained and the number of Naloxone kits given out each quarter. The information is required and will be sent to the Ministry of Health and Long Term Care.

Reporting dates for each quarter are listed below. Please submit on or before the due date.

Upon submission, a copy of this form will be sent to the email address specified on the form.

Reporting Period
  • Q1 - April 1 - June 30
  • Q2 - July 30 - September 30
  • Q3 - October 1 - December 31
  • Q4 - January 1- March 31
  • Due - July 10
  • Due - October 10
  • Due - January 10
  • Due - April 10
Organization Information
Contact Information
Naloxone Information
Additional Comments

Please provide any additional information that you feel is pertinent for the ministry to know about, including: Information about any drug trends in your community, a need for naloxone in your community that is not being filled, and/or successes and challenges of your naloxone distribution program.