Report a drug that has caused adverse effects

About the incident

Date of the incident:
If the exact date is not known please give an approximate

Location of incident

Please give as much information on the location as possible:

Details of the drug

Name of the drug (brand name, street name, chemical name etc) :

Describe what the drug looks like? (white powder, pill etc):

How they got the drug

Please tell us the price and whether this is per bag, pill, weight etc:

Details of any other drug or alcohol taken

Was the drug used with alcohol or another drug?

Alcohol
Another drug
Both
Not known

Describe what other drug or alcohol was used at the time of the incident:

Please give the amount taken for each drug or alcohol used:

Effect of the drug

Please give full details of the effect the drug had:

How was this different to what was expected? (lasted longer, more potent):

Treatment needed

Did the incident result in hospital treatment?

Yes
No

Hospital details

Which hospital were they taken to?

Were they taken to hospital:

By paramedics
They independently sought treatment

Did the incident result in death?

Yes
No

Harm resulting from the incident

Did the incident result in serious harm?

Yes
No

Their drug experience

Are they :

Experienced drug user
Recreational drug user
Naïve drug user
Not known

Your concerns

Please give any other concerns or information you think we should know:

Has this been raised by any other service users?

Yes
No
Not known

Other relevant information

Please give any other information you think may be helpful, for example any background details about the drug taker, such as a vulnerable adult, young person and their age, living in supported accommodation, street homeless and any known issues relating to the credibility of the person’s testimony.

Give details:

Contact details

Name:

Organisation:

Job title:

Email:

Tel:

Any other contact details you’d like us to have:

Data protection

The information you have provided on this form will be used to deal with your report by the relevant department. We may pass these details on to contracted third party service providers such as drug and alcohol provider services in Torbay and Devon. We will store a copy of your completed request as a backup for 12 months.

If you would like to know more about how we use your information and how you can exercise your information rights please see our privacy notice.

Do you accept these terms and conditions