Ontario Naloxone Program Quarterly Reporting Form – Community Distributors Ontario Naloxone Program Site Name(Required)Contact Name(Required)Contact Email(Required) Contact Telephone(Required)Reporting Quarter(Required) Q1 (Apr-Jun)- Due Aug 1 Q2 (Jul-Sept)- Due Nov 1 Q3 (Oct-Dec)- Due Feb 1 Q4 (Jan-Mar)- Due May 1 Select Organization Type(Required) ONP Core Site/ Naloxone Lead AIDS Service Organization Aboriginal Health Access Centre Community Health Centre Consumption and Treatment Service Emergency Department Expanded Access Organization Outreach Program Shelter Withdrawal Management Program Key Outcomes for the QuarterNumber of injectable naloxone kits distributed to individuals(Required)Number of single refill injectable ampoules distributed to individuals(Required)(1 box- 10 refill ampoules) Refill Categories: please only complete if you have placed a special order for refill doses. For reference, we would only mark these down at LPH for the doses that are provided to first respondersNumber of nasal spray naloxone kits distributed to individuals(Required)Number of single refill nasal sprays distributed to individuals(Required)(1 box- 2 refill sprays) Refill Categories: please only complete if you have placed a special order for refill doses. For reference, we would only mark these down at LPH for the doses that are provided to first respondersNumber of individuals trained to administer naloxone(Required)Refers to the number of individuals/clients your organization has trained when distributing a kit.Please provide information about drug trends in your community and/or a need for naloxone in your community that is not being filled