Get Pa Naloxone Administration Form - Cambria County 2015-2026

Filling out the PA Naloxone Administration Form is an important step in documenting naloxone administration in response to an overdose incident. This guide will provide you with clear instructions on how to complete the form online efficiently and accurately.

Follow the steps to fill out the form correctly

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. In the 'Agency Name' field, enter the name of the agency that is reporting the overdose incident.
3. Fill in the 'Time of Overdose' with the exact time when the incident occurred, selecting AM or PM as appropriate.
4. Input the 'Date of Overdose' by selecting the relevant date from the calendar provided in the form.
5. Enter the 'Agency Incident Number' for internal tracking purposes.
6. Indicate the 'County' where the overdose occurred.
7. Provide the 'City' where the overdose took place under the 'Overdose Occurred' section.
8. Input the victim's 'Age' in years.
9. Select the 'Gender of the Victim' by marking the appropriate box.
10. Fill in the 'Zip Code' of the victim's residence.
11. Provide the 'City,' 'State,' and 'Zip Code' of where the victim resides.
12. Select the victim's 'Race/Ethnicity' from the provided options, marking 'Unknown' if applicable.
13. Indicate whether the victim has received naloxone in the past by selecting 'Yes' or 'No.'
14. Check all suspected drugs involved in the overdose under 'Suspected Overdose on What Drugs?'. You may select multiple options.
15. Fill in the 'Evidence' section if any evidence was secured related to the overdose.
16. In the 'Details of Naloxone Administration' section, enter how many doses you administered.
17. List the number of doses administered by other responders, including EMS, law enforcement, and bystanders.
18. Specify how long it took for the naloxone to work by marking the relevant time frame.
19. Describe the person's response to naloxone by selecting the most appropriate option.
20. Indicate whether the person survived the overdose by selecting 'Yes,' 'No,' or 'Unknown.'
21. If the victim was revived, specify what happened next by choosing from the provided options.
22. Enter the naloxone lot number and expiration date.
23. Add any 'Notes/Comments' relevant to the incident.
24. Fill in the responder's name, signature/date, and contact phone number.
25. Once all fields are completed, save changes, download, print, or share the form as necessary to ensure submission.

Complete your PA Naloxone Administration Form online to contribute to local overdose response efforts.