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 Naloxone Kit Monthly Distribution Report  
 Please note that reports are due on the 8th of the following month. (e.g. Report for January is due by February 8th.)

Thank you for completing the Naloxone Kit Monthly Distribution Report. Your distribution data is used to evaluate our program and ensures Albertans have access to our life saving Naloxone Kits.  
 

 
 
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This is the email address for the person who is currently listed as the primary contact for the site.
 
   
 
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Do not use spaces (e.g. T2N3N8)
 
   
 
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(count the total number of kits in stock at end of reporting month) *Note: stock levels should match kit orders and kit distribution counts
 
   
 
(e.g. missing kits, kits expired and disposed, kits stolen from site, kits tampered with).
 
   
 
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(these clients may or may not have received a kit)
 
   
 
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(this number includes first-time and replacement kits)
 
   
 
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(these clients may or may not have received a replacement kit)
 
   
 
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*Note: Replacement kits are the kits given to people who have previously owned a Naloxone kit from any source.
 
   
  How many of the replacement kits were provided for each of the following reasons?
   
 
 
   
 
 
   
 
 
   
 
 
   
 
 
   
 
 
   
 
 
   
 
 
 Done