Broome County Drug Overdose Report - for Police

This form should be filled out and submitted by a responding police officer in all overdose incidents (Fatal and Non-fatal). Direct any questions to the on-call Assistant District Attorney at (607) 778-1122.

Incident Information



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Enter the date of the Incident.
Enter the time of the incident.
Enter the unique Case Number for this incident.
Enter the street address where the incident occurred.
Enter the town, village or city where the incident occurred.
Enter the state where the incident occurred.
Enter the name of the responding agency. If more than one, list all who responded.
Select one.
Was Narcan used?
Enter the Hospital name where the Victim was transported.
Enter the name of the Coroner that was called.
If the Victim wasn't transported to a hospital and the Coroner wasn't called, enter here what happened to end the call. IE: refused treatment, etc.
Enter the full name of the Victim.
Enter the Victim's date of birth, mm/dd/yy format.
Enter the Victim's sex, male or female.
Enter the Victim's residence street address.
Enter the victim's town, village, or city of residence.
Enter the Victim's state of residence.
Enter the Victim's zip-code of residence.
Enter Victim's phone #, if known.
Was the Victim's phone seized? (Yes/No)
Were drugs seized?
Enter your name.
Enter the agency you represent.
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Enter the characters shown in the image.