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Get PA Naloxone Administration Form - Cambria County 2015-2024

DATE OF OVERDOSE AGENCY INCIDENT NUMBER AM PM County OVERDOSE OCCURRED - City AGE GENDER OF THE VICTIM Male Female Zip Code VICTIM RESIDENCE - City State Zip Code RACE/ETHNICITY OF THE VICTIM Unk. White HAS THE VICTIM RECEIVED NALOXONE IN THE PAST? Hispanic Black Yes Asian/Indian No Native American Pacific Islander Unknown Suspected Overdose on What Drugs? (Check all that apply.) Heroin Benzos/Barbituates Cocaine/Crack Unknown Alcohol Other (speci.

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