2. WASHINGTON COUNTY OVERDOSE TRACKING
4. REPORTING AGENCY*
   -- Select One --Argyle EMSCambridge EMSFort Ann EMSFort Edward EMSGranville EMSEaston-Greenwich EMSSalem EMSSkenesborough EMSFair Haven EMSPoultney EMSWashington County Coroner's OfficeCambridge-Greenwich Police DepartmentGranville Police DepartmentHudson Falls Police DepartmentWhitehall Police Department
6. CALL DATE*
   CALL DATE

   CALL DATE
7. CALL LOCATION TOWN / VILLAGE*
   -- Select One --Argyle (Town)Argyle (Village)Cambridge (Town)Cambridge (Village)DresdenEastonFort Ann (Town)Fort Ann (Village)Fort Edward (Town)Fort Edward (Village)Granville (Town)Granville (Village)Greenwich (Town)Greenwich (Village)HamptonHartfordHebronHudson FallsJacksonKingsburyPutnamSalemWhite CreekWhitehall (Town)Whitehall (Village)
9. AGE OF PATIENT*
10. PATIENT GENDER*
    -- Select One --MaleFemale
11. RACE*
    -- Select One --WhiteBlackHispanicAsianUnknownOther
13. SUSPECTED DRUG(S) USED*
    -- Select One --AlcoholBenzodiazepineCocaineCrackFentanylHeroinMDMAMethadoneMethamphetamineOxycodonePCPPrescription DrugsOther
14. WAS NARCAN ADMINISTERED?*
    -- Select One --YesNo
15. IF YES, HOW MANY DOSES ADMINISTERED?
17. NARCAN ADMINISTERED BY:*
    -- Select One --Law EnforcementEmergency Medical ServicesFire / First RespondersBystanderN/AOther
18. TREATMENT*
    -- Select One --TransportedRefused TreatmentN/A
20. OVERDOSE OUTCOME
    -- Select One --Non-FatalFatal
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