Community Naloxone Usage Report

NYSDOH Opioid Overdose Prevention Initiative

Community Naloxone Usage Form
As a community responder it is your responsibility to notify the Program Agency (Coventry Emergency Squad, Inc) that you have used Naloxone and complete the below form. This will prompt the Program Agency to issue a new Response Kit to you.
Name*

First NameLast Name
Kit Number*
On what day was the naloxone used? If naloxone was used on more than one day, please submit a separate report for each use. If you don't know the precise date, choose one that you think is close. *

MonthDayYear
Date
Do you know the zip code where the overdose happened?
Yes: Zip Code
No: County/ Borough & Town
YesNoI Don't Know
Narcan Nasal SprayIntramuscular Injection GenericNasal Spray GenericEvizio Autoinjector
1234More than 4Don't Recall
YesNoI Don't Know
PoliceEMSFire FightersAnother Civilian witness or bystanderOther
YesNo
Narcan Nasal SprayIntramuscular Injection GenericNasal Spray GenericEvizio Auto Injector
1234More than 4I Don't Recall
YesNoI Don't Know
YesNoI Don't Know
YesNoI Don't Know
How old were they? (Best Guess)*
MaleFemaleTransgender or gender non conformingUnknown SexOther
African-American/ BlackAsian/Pacific IslanderHispanic/Latino(a)Native AmericanWhiteUnknown race/ethnicityOther
HeroinPain PillsCocaineFentanylBenzosAlcoholAmphetamine/MethamphetamineMethadoneOther
Someone's home or apartmentShelter or in a supportive housing settingAgency or Facility that provides services, such as a syringe exchange, drug treatment program or social services agency or government officePublic place OUTSIDE (e.g. park, sidewalk, yard)Public place INSIDE other than a library, secondary school, or college/university/trade school campus (e.g. restroom, business, train, car)LibrarySecondary School (e.g. high school, middle school)On a Collage/ University/ Trade School CampusOther
Friend or acquaintanceFamilyStrangerPatient or ClientPrefer not to answerOther
YesNoI Don't Know
Please add any additional comments about this naloxone administration.
- YesNoI Don't Know
- YesNoI Don't Know
- YesNo
- Date
  
  MonthDayYear
  Date
- Kit Replacement Number
- Training Coordinator Signature:
  
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- Should be Empty:

NYSDOH Opioid Overdose Prevention Initiative