Naloxone Reporting System (NRS)

Naloxone Reporting System (NRS)

Report each Naloxone (Narcan®) use to Calaveras County Public Health.
1. Date of use*

MonthDayYear
Date
2. Location of use (select nearest location)*
3. Location of the overdose?*

Place of residence (home, RV, motel, shelter, apartment, etc.)Outdoor public space (park, street, sidewalk, etc.)SchoolPlace of business (restaurant, office, etc.)Hospital or ClinicUnknownOther
4. What signs was the patient presenting with prior to administration? (select all that apply)*

Unresponsive or unconsciousSlow pulseNo pulseBreathing slowlyNot breathingBlue lipsUnknownOther
5. How many sprays were administered to the patient?*

1

2

3

4

1 is , 4 is
6. Did the administration of Narcan stop the overdose? (relieve signs of overdose)*

YesNoUnknown
7. Did the patient survive?*

YesNoUnknown
8. Did the person who administered the spray feel comfortable using it?*

YesNoUknown
10. Patient's age group?*

< 18 years old18-29 years old30-39 years old40-49 years old50-59 years old60+ years oldUnknown
11. Patient's gender?*

MaleFemaleTrans male/trans maleTrans female/trans womanGenderqueer/non-binaryIdentity not listed hereDeclined to answerUnknown
Hidden: Tracking
Schools, First Responders, Other Govt Workers, General Public
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