Methadone Death and Incident Review System

Tuesday, September 01, 2015

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.


Individual Filing Report
  1.    
  2. ( ) -
Information regarding the individual involved in incident or death
  1.     
  2. (mm/dd/yyyy):      
  3. (city and state):  

  4. (Please include how methadone was a contributing factor to the incident/death):

    Max 2,000 characters.

  5. Max 2,000 characters.





  6. Medical Providers (including drug treatment):
         
    ( ) -
  • Security Verification

    Type the characters exactly as shown: