Red Project Naloxone Use Report
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Date of naloxone use: *
MM
/
DD
/
YYYY
County of incident: *
If "other", what is the county of incident?
Zip code of incident:
Use "00000", if unknown
Primary medication/substance involved: *
Other:
Secondary medication/substance involved, if applicable:
Other:
How long was the person unresponsive for before naloxone was administered?
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How much naloxone was needed?
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How was the naloxone administered?
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Was rescue breathing provided?
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If yes, was the rescue breathing barrier used?
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Did the overdose return as the naloxone wore off?
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If yes, how long did it take for the overdose to return?
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Did the individual experience any withdrawal symptoms from being brought out of the overdose?
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If yes, which symptoms?
Did anyone call 911 regarding the overdose? *
Was the individual transported to the hospital? *
Additional notes:
Please do not include any identifying information
Do you need a replacement kit?
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If yes, please provide your first name and phone number so a Red Project staff member can follow up:
Red Project Participant ID, if applicable:
How did you complete this form?
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