Get Naloxone Usage Form

Completing the Naloxone Usage Form is a critical step in documenting overdose incidents and the subsequent response. This guide will provide you with clear and detailed instructions on how to fill out the form online effectively.

Follow the steps to fill out the Naloxone Usage Form carefully.

1. Press the ‘Get Form’ button to retrieve the Naloxone Usage Form and open it in your editor.
2. Begin by filling out the 'Arrival Time of Officer' section to indicate the time you arrived at the scene.
3. Enter the 'Date of Overdose' by selecting the appropriate date in the provided format.
4. Add the 'Zip Code Where Overdose Occurred' to specify the location of the incident.
5. Select the 'Gender of the Person Who Overdosed' by choosing from the options: female, male, or unknown.
6. Complete the 'Age' field to provide the age of the individual involved in the overdose.
7. Indicate the 'County Where Overdose Occurred' to specify the geographical area.
8. In the 'Aided Status Prior to Administering Naloxone' section, check one option in each of the three categories: Responsiveness, Breathing, and Pulse.
9. List any drugs that the individual may have overdosed on by selecting all applicable options from the 'Aided Overdosed on What Drugs?' section.
10. Fill in the number of vials of Naloxone used in the designated space.
11. State the time it took for the Naloxone to take effect by selecting from the response options provided.
12. Describe the aided individual's response to Naloxone by selecting the appropriate option.
13. Check all relevant symptoms exhibited after Naloxone administration in the 'Post-Naloxone Symptoms' section.
14. Indicate what actions were taken by the officer on the scene in the 'What else was done by officer?' section.
15. Specify if Naloxone was administered by anyone else present, marking any relevant options.
16. Choose the appropriate disposition based on the outcome, indicating whether the person lived or not.
17. Provide any additional comments in the 'Comments' section to clarify the incident further.
18. Fill in your information as the administering officer in the 'Administering Officer's Information' section, including agency, last name, first name, and shield number.
19. Once you have completed the form, save your changes. You can then download, print, or share the form as needed.

Take action now by completing the Naloxone Usage Form online.