Narcan Usage Form
Email address *
Your answer
Agency *
Your answer
Administering Responder's Information
Administering Responder's Information *
Agency Type: *
Badge Number
Your answer
Your Name/ Name of Lead Responder *
Your answer
Run Number/Agency Case Number
Your answer
Overdose Information
County Where Overdose Occurred *
Date of Overdose *
MM
/
DD
/
YYYY
Zip Code Where Overdose Occurred *
Your answer
Arrival Time of Responder
Time
:
Arrival Time of EMS
Time
:
Gender of the Person Who Overdosed *
Age:
Your answer
Aided Status Prior to Administering Naloxone
Responsiveness: *
Breathing: *
Breaths per minute
Your answer
Pulse: *
Beats per minute
Your answer
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:
How long after 1st dose was 2nd dose administered?
2nd Aided's Response:
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:
Did the Person Live? *
Hospital Destination: *
Your answer
Transporting Ambulance: *
Your answer
Comments:
Your answer
If you need a new Narcan kit, please contact Southern Tier Health Care System at (716) 372-0614 or jciminesi@sthcs.org.
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