Methadone Death and Incident Review System
Wednesday, September 28, 2016
Methadone Death and Incident
General Public Reporting Form
We understand you may not have all the requested information. Please provide whatever information you have available below.
Report Type:
-- Select --
Incident
Death
Individual Filing Report
First Name:
Last Name:
Contact Phone #:
(
)
-
Relationship to individual involved in death or incident:
-- Select --
Family Member
Friend
Community Provider
No Relationship
Information regarding the individual involved in incident or death
First Name:
Last Name:
Client Age:
Client Gender:
-- Select --
Male
Female
Transgender (MtF)
Transgender (FtM)
Other
Date of death or incident
(mm/dd/yyyy):
Location of death or incident
(city and state):
AL
AK
AZ
AR
CA
CO
CT
DC
DE
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
Manner of death:
Natural
Accident
Suicide
Homicide
Other
Description of incident
(Please include how methadone was a contributing factor to the incident/death):
Max 2,000 characters.
Was anyone else harmed as a result of this death/incident:
No
Yes
Max 2,000 characters.
Source providing methadone:
Drug Treatment Program
Illicit Source
Unknown
Physician
Methadone dosage at the time of incident or death:
Any other prescription and/or other drug use?
No
Yes
Name of other drug (including prescriptions)
Dosage (if any)
Frequency
Other medical conditions:
Is this matter being investigated?
No
Yes
Medical Providers (including drug treatment):
Provider Name:
Address 1:
Address 2:
City:
State:
AL
AK
AZ
AR
CA
CO
CT
DC
DE
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
Zip:
Phone:
(
)
-
Security Verification
Type the characters exactly as shown: