Form Grantee-Level Inst Grantee-Level Inst Grantee-Level Instrument

State Opioid Response (SOR) /Tribal Opioid Response (TOR) – Program Instrument

For all program-specific questions below, consider the past three months as the reporting time period. Information and data should be reported for all programs/services either funded wholly or in part by SOR/TOR grant funds.

For all questions below, if unable to answer a question that requires a number, please indicate the reason as follows:

1 DATA UNAVAILABLE

2 DATA AVAILABLE, BUT UNABLE TO OBTAIN IN ALLOTTED TIME

3 DATA AVAILABLE, BUT INCONSISTENT IN DIFFERENT DATA SOURCES

4 OTHER (Specify the reason following the section in the space provided).

	Naloxone Overdose Reversal Kit Distribution and Utilization
1	Has your state/territory/tribal entity used SOR/TOR funds to expand the availability, distribution, and use of naloxone overdose reversal kits (Narcan, Evzio, and others)? Yes/No
1a	If “Yes,” how many naloxone overdose reversal kits have been purchased (funded) wholly or in part since the last reporting period with SOR/TOR funds? ____ kits If information is unavailable, please indicate why using the codes provided above________________
1b	If “Yes,” how many naloxone overdose reversal kits funded wholly or in part by SOR/TOR funds have been distributed since the last reporting period? ____ kits If information is unavailable, please indicate why using the codes provided above________________