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
Did the person who overdosed survive?*

YesNoI Don't Know
Select the type of naloxone used:*

Narcan Nasal SprayIntramuscular Injection GenericNasal Spray GenericEvizio Autoinjector
How Many Doses Given?*

1234More than 4Don't Recall
Did anyone else also give naloxone for this same overdose?*

YesNoI Don't Know
Were there: (Check all that apply)

PoliceEMSFire FightersAnother Civilian witness or bystanderOther
Do you know what type of naloxone THEY used?

YesNo
Select the type of naloxone THEY used:

Narcan Nasal SprayIntramuscular Injection GenericNasal Spray GenericEvizio Auto Injector
How many doses were given:

1234More than 4I Don't Recall
Was 911 called?*

YesNoI Don't Know
Was rescue breathing preformed before EMS, police or firefighters arrived?*

YesNoI Don't Know
Were chest compressions preformed before EMS, police or firefighters arrived?*

YesNoI Don't Know
How old were they? (Best Guess)*
Were they:*

MaleFemaleTransgender or gender non conformingUnknown SexOther
Were they:*

African-American/ BlackAsian/Pacific IslanderHispanic/Latino(a)Native AmericanWhiteUnknown race/ethnicityOther
Select which drugs the overdoser is likely to have used:*

HeroinPain PillsCocaineFentanylBenzosAlcoholAmphetamine/MethamphetamineMethadoneOther
In what kind of place did the overdose happen?*

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
What is the relationship to the person who overdosed?*

Friend or acquaintanceFamilyStrangerPatient or ClientPrefer not to answerOther
Has this person experienced an opioid overdose in the past?*

YesNoI Don't Know
Please add any additional comments about this naloxone administration.

Training Coordinator Section
Was a replacement kit given?

YesNoI Don't Know
Was information provided about getting naloxone from a pharmacy?

YesNoI Don't Know
Reported to NYS OOPPS?

YesNo
Date

MonthDayYear
Date
Kit Replacement Number
Training Coordinator Signature:

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NYSDOH Opioid Overdose Prevention Initiative