Tools Load unfinished survey Resume later default Caution: JavaScript execution is disabled in your browser or for this website. You may not be able to answer all questions in this survey. Please, verify your browser parameters. DOPE Unified Form V1.2 This survey is used to document naloxone distribution to any participant, new or old.. Welcome to the DOPE Unified data collection form v1.0 (This question is mandatory) Date of service The date the registration was conducted Please complete all parts of the date. Answer must be between 01/01/2003 and 03/05/2026 Month Month Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec / Day Day 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 / Year Year 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 2021 2022 2023 2024 2025 2026 Date in the format: MM/DD/YYYY Format: MM/DD/YYYY Trainer name (This question is mandatory) Site Choose one of the following answers SFAF sites HYA/SFNE Glide St. James Infirmary UCSF TCRC (UFO/VIP) Martin De Porres MNRC SF Drug Users Union SF County Jail pods SF Community Health Center At the Crossroads SFDPH sites Shanti Project Gubbio Project: St. John's SFHOT HH (Hospitality House) sites HopeSF sites Other: (This question is mandatory) SFAF Site Choose one of the following answers 6th St Hemlock Bayview Duboce Wiese St 16th & Mission Outreach Peer Harm Reduction Workers County Jail Pod # (This question is mandatory) SFDPH site Choose one of the following answers CHEP/CHRT SURU Which HH site? Choose one of the following answers Leavenworth 6th St Turk Other: No answer Which HopeSF site? Choose one of the following answers Sunnydale Hunters View Potrero Hill Alice Griffith Other: No answer Has this person ever received naloxone from DOPE before? Choose one of the following answers New registration (person has never received naloxone from DOPE Project before Refill No answer Participant gender Choose one of the following answers Female Male Transman Transwoman Gender non-conforming/non-binary Other: No answer Participant ethnicity Select all that apply Black/ African American White Latinx Asian/Pacific Islander Native American/American Indian Other: Last night, where did you stay Choose one of the following answers Outdoors (including car, camp, etc) Hotel (SRO) Shelter Supportive housing or program Your own private housing (apartment, house) Someone else's housing (apartment, house) Jail Other: No answer What age range is this person? Choose one of the following answers 17 or under 18-24 25-34 35-44 45-54 55-64 65 or older No answer Which of these drugs did you use in the last 30 days? Select all that apply None Decline Heroin Fentanyl Pharmaceutical opioids (Morphine, Percocet, Roxycodone, Oxycodone, Vicodin, Fentanyl etc) Methadone Buprenorphine (Suboxone, Subutex) Benzos (Klonopin, Xanax, Ativan, Valium, Librium etc) Cocaine / Crack Alcohol Methamphetamine Other: Have you ever overdosed? Select all that apply Yes No Not sure Have you ever seen an overdose? Select all that apply Yes No Not sure Have you ever used naloxone/Narcan before? Yes No No answer (This question is mandatory) Reason for refill Choose one of the following answers I used my narcan DPW confiscated my stuff (including my narcan) Someone stole my stuff (including my narcan) I gave it away It expired I just lost it Police confiscated it Other: Please give as much info as possible about the police confiscation (badge #, name of officer, neighborhood..) Date of the overdose Please complete all parts of the date. Month Month Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec / Day Day 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 / Year Year 1900 1901 1902 1903 1904 1905 1906 1907 1908 1909 1910 1911 1912 1913 1914 1915 1916 1917 1918 1919 1920 1921 1922 1923 1924 1925 1926 1927 1928 1929 1930 1931 1932 1933 1934 1935 1936 1937 1938 1939 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 2021 2022 2023 2024 2025 2026 2027 2028 2029 2030 2031 2032 2033 2034 2035 2036 2037 2038 2039 2040 2041 2042 2043 2044 2045 2046 2047 2048 2049 2050 2051 2052 2053 2054 2055 2056 2057 2058 2059 2060 2061 2062 2063 2064 2065 2066 2067 2068 2069 2070 2071 2072 2073 2074 2075 2076 2077 2078 2079 2080 2081 2082 2083 2084 2085 2086 2087 2088 2089 2090 2091 2092 2093 2094 2095 2096 2097 2098 2099 2100 2101 2102 2103 2104 2105 2106 2107 2108 2109 2110 2111 2112 2113 2114 2115 2116 2117 2118 2119 2120 2121 2122 2123 2124 2125 2126 2127 2128 2129 2130 2131 2132 2133 2134 2135 2136 2137 2138 2139 2140 2141 2142 2143 2144 2145 2146 2147 2148 2149 2150 2151 2152 2153 2154 2155 2156 2157 2158 2159 2160 2161 2162 2163 2164 2165 2166 2167 2168 2169 2170 2171 2172 2173 2174 2175 2176 2177 2178 2179 2180 2181 2182 2183 2184 2185 2186 2187 Date in the format: MM/DD/YYYY Format: MM/DD/YYYY Who overdosed? Choose one of the following answers Friend Partner/spouse Stranger/Aquaintance Family member Client/program participant I did Other: No answer What was the gender of the person who OD'd? Choose one of the following answers Female Male Transman Transwoman Gender non-conforming/non-binary Other: No answer What was their approximate age? Only numbers may be entered in this field. What drugs had they taken? Only check ones you're sure of Select all that apply Heroin Fentanyl Pharmaceutical opioids (Morphine, Percocet, Roxicodone, Oxycodone, Vicodin, Fentanyl etc) Methadone Buprenorphine (Suboxone, Subutex) Benzos (Klonopin, Xanax, Ativan, Valium, Librium etc) Cocaine / Crack Alcohol Methamphetamine Other: What type of place did it occur in? Choose one of the following answers Private house/apartment Public park Public bathroom Hotel/SRO room Street/alley/camp Vehicle (car, camper/RV etc) BART/MUNI station Program (treatment/housing, drop-in etc) Other: No answer Where did the overdose take place? Choose one of the following answers In San Francisco Outside SF but in the Bay Area (Oakland, Berkeley, Richmond, Hayward, Fremont, etc) Outside the Bay Area No answer If in San Francisco, what was the closest intersection (NOT EXACT ADDRESS)? How did you revive the person (or if reporting about your own OD, what did the person do to revive you)? Select all that apply Stimulation (pinch, sternum rub etc) 911 was called by myself or someone else Rescue breathing/CPR Gave naloxone/narcan What kind of narcan and how many doses did you give? Only numbers may be entered in these fields. Nasal # of doses Injectable # of doses Auto-injector # of doses How long did it take for the naloxone/narcan to work? If 'It didn't work' please give details in the box at the end of the survey! Choose one of the following answers Less than 1 minute 1-3 minutes 3-5 minutes More than 5 minutes It didn't work No answer Please use this space to document anything else about the overdose that the participant wants us to know: eg problems using the naloxone, medical complicatons following naloxone use, problems with the police, new drugs.. Trainer: At the end of training, participant should be able to successfully assemble and use narcan, identify and respond to an overdose and knows where and how to get a refill. Naloxone dispensed under standing order from Dr. Phillip Coffin, MD Type and number of kits given Comment only when you choose an answer. Nasal # of kits Injectable # of kits Auto-injector # of kits No narcan given (ignore number field) Naloxone lot # Naloxone expiry date Please complete all parts of the date. Answer must be greater or equal to 03/05/2025 Month Month Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec / Day Day 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 / Year Year 2025 2026 2027 2028 2029 2030 2031 2032 2033 2034 2035 2036 2037 2038 2039 2040 2041 2042 2043 2044 2045 2046 2047 2048 2049 2050 2051 2052 2053 2054 2055 2056 2057 2058 2059 2060 2061 2062 2063 2064 2065 2066 2067 2068 2069 2070 2071 2072 2073 2074 2075 2076 2077 2078 2079 2080 2081 2082 2083 2084 2085 2086 2087 2088 2089 2090 2091 2092 2093 2094 2095 2096 2097 2098 2099 2100 2101 2102 2103 2104 2105 2106 2107 2108 2109 2110 2111 2112 2113 2114 2115 2116 2117 2118 2119 2120 2121 2122 2123 2124 2125 2126 2127 2128 2129 2130 2131 2132 2133 2134 2135 2136 2137 2138 2139 2140 2141 2142 2143 2144 2145 2146 2147 2148 2149 2150 2151 2152 2153 2154 2155 2156 2157 2158 2159 2160 2161 2162 2163 2164 2165 2166 2167 2168 2169 2170 2171 2172 2173 2174 2175 2176 2177 2178 2179 2180 2181 2182 2183 2184 2185 2186 2187 Date in the format: MM/DD/YYYY Format: MM/DD/YYYY Submit Load unfinished survey Resume later Please confirm you want to clear your response? 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