Narcan Usage Form
Email address *
Agency *
Administering Responder's Information
Administering Responder's Information *
Agency Type: *
Badge Number
Your Name/ Name of Lead Responder *
Run Number/Agency Case Number
Overdose Information
County Where Overdose Occurred *
Date of Overdose *
MM
/
DD
/
YYYY
Zip Code Where Overdose Occurred *
Arrival Time of Responder
Time
:
Arrival Time of EMS
Time
:
Gender of the Person Who Overdosed *
Age:
Aided Status Prior to Administering Naloxone
Responsiveness: *
Breathing: *
Breaths per minute
Pulse: *
Beats per minute
Aided Overdosed on What Drugs
Drug - Check all that apply. *
Required
Administration of Naloxone
Number of naloxone vials used: *
First dose method: *
How long did 1st dose of naloxone take to work? *
Aided's Response: *
If 2nd dose was given, was it:
Clear selection
How long after 1st dose was 2nd dose administered?
Clear selection
2nd Aided's Response:
Clear selection
Post-Naloxone Symptoms (Check all that apply.) *
Required
What Else was Done by the Responder?
What Else was Done by the Responder (Check all that apply)? *
Required
Was Naloxone Administered by Anyone Else at the Scene? (Check all that apply.) *
Required
Disposition:
Clear selection
Did the Person Live? *
Hospital Destination: *
Transporting Ambulance: *
Comments:
If you need a new Narcan kit, please contact Southern Tier Health Care System at (716) 372-0614 or prevention@sthcs.org.
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