Teva Naloxone Recipient Survey

All organizations that received Teva naloxone directly from the Attorney General’s Office are required to submit answers to the survey questions below. Please submit a report at the end of each quarter until all your supplies have been depleted. Fill out the form below and hit the submit button when you have completed it. You may not save your work and return later. The form must be completed in one session. Please contact me at [email protected] with any questions. Thank you for your cooperation!

Jane Fallon, Assistant Attorney General
Arizona Attorney General’s Office

Quarter of Report

2Q2024

3Q2024

4Q2024

1Q2025

2Q2025

3Q2025

4Q2025

Name of Contact Person

Organization

Email

Phone

Inventory of Naloxone (2 Kits per Unit)

Number of units of naloxone received from the AGO (each unit has two kits, so report the number of units)

Date Received

Number of units of naloxone remaining (each unit has two kits, so report the number of units):

Date Counted

Distribution of Naloxone:

Entities to whom naloxone units were distributed:

Name of Local Recipients

Re-order	Name of Recipient	Type of Recipient	Number of Units	Weight	Operations
	Name of Recipient	Type of Recipient	Number of Units	Item weight

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Total Number of Units Distributed (each unit has two kits, report the number of units):

As of Date:

Training Conducted:

Number of people trained on opioid overdose recognition and naloxone administration

Number of General Public Trained:

Number of First Responders Trained:

Overdose Reversals Reported By Source:

Overdose Reversals by Source

Re-order	Source of Report	Number of Reversals	Weight	Operations
	Source of Report	Number of Reversals	Item weight

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Total Reversals

Overdose Reversal Stories

Please provide a brief narrative recounting overdose reversal stories shared with your organization, i.e., what happened, who was involved, how did it turn out, when did this occur, where did it take place, why was this an important story, etc.

Agency Successes

Brief statement of achievements.

Agency Obstacles

Brief statement of challenges faced.