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Monthly Narcan Reporting
This form must be reported to the state monthly. Please answer the questions as accurately as you are able to.
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Date Narcan was used *
Name of individual who administered *
How were we called to the scene? *
What was the setting of the incident? *
# of units of Narcan administered to a single person? *
What substance was consumed prior to the overdose? *
What was the outcome for the individual? *
Patient's race? *
Patient's age? (If unknown, give an estimate) *
Patient's gender? *
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