We are collecting information through this form to understand overdoses and negative drug reactions in our community. This information will allow us to identify if there is a tainted or potent drug supply or an increase in overdoses so that we can respond and reduce drug-related deaths or harms. Please provide as much information as possible. If your client does not feel comfortable answering a question, or you didn’t get the chance to ask them some questions, fill in as much information as you know. In a situation where more than one person had an overdose or negative drug reaction, please submit a separate form for each person. If you have any questions about this form, please contact Auburn Larose at john.mitchell@healthunit.ca or 705-474-1400 ext 5368. 1. Name of the person completing this form: 2. Organization/agency of the service provider completing this form: --- AIDS Committee of North Bay & Area Alliance Centre Community Counselling Centre of Nipissing Children’s Aid Society CMHA Muskoka Parry Sound CMHA Nipissing Esprit Place Fire Service (type the department name in the 'other' box below) First Nations Inuit Health Branch Mattawa General Hospital Nipissing DSSAB Nipissing EMS Nipissing First Nation Health Services North Bay Indigenous Friendship Centre North Bay Parry Sound District Health Unit North Bay Recovery Home North Bay Regional Health Centre Parry Sound EMS Parry Sound Friendship Centre Parry Sound DSSAB Police Service (type the detachment name in the 'other' box below) Shawanaga First Nation Health Services West Nipissing CHC West Parry Sound Health Centre Other (Please specify below) --- Other (if you chose 'other' above, specify here): 3. What is the age of the person who had a negative reaction or overdose? If you don't know the age of the person please enter an approximate age. --- Armour Bonfield Burk's Falls Callander Calvin Carling Chisholm Dokis First Nation East Ferris Henvey Inlet First Nation Joly Kearney Machar Magnetawan Magnetewan First Nation Mattawa Mattawan McDougall McKellar McMurrich/Monteith Nipissing Township Nipissing First Nation Nipissing, Unorganized, North Part Nipissing, Unorganized, South Part North Bay Papineau-Cameron Parry Sound Parry Sound, Unorganized, Centre Part Parry Sound, Unorganized, North East Part Perry Powassan Ryerson Seguin Shawanaga First Nation South River Strong Sundridge The Archipelago Wasauksing First Nation West Nipissing / Nipissing Ouest Whitestone Outside of Nipissing or Parry Sound District. --- Thibeault Terrace / Cedar Heights Pinewood City Central (Downtown/Old City) Graniteville/Laurentian Birchaven/Circle Lake Wallace Heights/Airport West Ferris