Naloxone Use Report

Naloxone Use Report
Dr.Prof.Mr.Ms.
Full Name*

First NameMiddle NameLast NameSuffix
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Phone Number

Area CodePhone Number
E-mail Address
Consumer/ClientFamily Member/Friend/Personal ContactCommunity MemberLaw EnforcementFirst Responder other than Law EnforcementProfessional Staff
Agency Name (if Applicable)
Date of Overdose*

MonthDayYear
Date
HerionMethadonePrescription OpioidUnknown
YesNoUnknownType option 4
CocaineAlcoholValium/Xanax/Ativan/KlonopinClonidinePCPSpeed (including Crystal)
Less than 5 Minutes5 -15 MinutesMore than 15 MinutesUnknown
How many doses of Naloxone were used?*
YesNo
YesNoRescue Breaths were not done
YesNoThe Individual Did Not LiveUnknown
Less than 30 Minutes30 - 60 MinutesMore than 60 Minutes
YesNoUnknown
YesNoUnknown
YesNoUnknownType option 4
Other Comments:
Should be Empty: