DuPage NARCAN Program (DNP) Re-Supply Request

Program Site*
First Name*
Last Name*
Phone Number*
E-mail*
Number of Narcan doses requested (2 doses in each box)*
Product Type Used and/or Requested*
Number of Recalled Narcan Atomizers requested *
Reason for request*

Use of kitLoss/Damage/Other resupplyAdditional Trained PersonnelExpired ProductInitial SupplyCommunity DistributionVending Cabinet Naloxone DistributionAtomizer Recall - Indicate number of atomizers in above doses section
Date of Use*

MonthDayYear
Date
Save?*

YesNoUnknown
Note: Each individual being trained will be issued one kit which contains two doses of Naloxone. Example, If you have 20 individuals needing to be trained, then you should request 40 doses.
Month & Year (xx-xxxx) NOTE: The product expires on the last day of the month listed.*
Information on Individual saved:
Sex

MaleFemaleTransgenderIntersexUnknown
Race

African American/BlackAsian/Pacific IslanderHispanic/LatinoNative AmericanWhite/CaucasianUnknown
Age
PLEASE USE THE LATEST VERSION OF THE DRUG OVERDOSE REVERSAL AND NALOXONE ADMINISTRATION REPORTING FORM
How are you submitting Drug Overdose Reversal and Naloxone Administration Reporting Form ?*

Attaching saved copy with this form (PREFERRED)Emailing saved copy to DNP@dupagehealth.org (ALSO SUBMIT THIS FORM BELOW IF EMAILING)
Please describe what happened to the kits (Lost/Damaged plus a description of incident)
Attach the completed "Drug Overdose Reversal and Naloxone Administration Reporting Form" by clicking select file button below. If you have not yet filled out the form and need to do so at this time you can click on "save" on the bottom right and return to this form (filled out) after you have completed the Drug Overdose Reversal and Naloxone Administration Reporting Form. An email will be sent with instructions to return to the saved form once you click save.
Use Form Attachment*

Select File

Cancelof
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