PA Naloxone Administration Form - Cambria County 2015-2025 free printable template

Naloxone Administration Form Please return completed forms to the Cambria County Drug and Alcohol Program Email: shershberger@co.cambria.pa.us OR Fax: 8145366867 AGENCY NAME TIME OF OVERDOSED ATE

How to fill out naloxone administration form

How to fill out PA Naloxone Administration Form - Cambria County

1. Obtain the PA Naloxone Administration Form from a reliable source.
2. Fill out the date of the incident at the top of the form.
3. Provide the name and contact information of the individual administering the naloxone.
4. Record the location where the naloxone was administered.
5. Document the name and details of the individual who received naloxone, including any relevant medical history.
6. Indicate the dosage and route of administration of the naloxone.
7. Note the time of administration.
8. Include any additional comments or observations about the incident.
9. Sign and date the form to verify the information provided.

Who needs PA Naloxone Administration Form - Cambria County?

1. Individuals who administer naloxone to someone experiencing an opioid overdose.
2. First responders such as police officers, firefighters, or emergency medical personnel.
3. Community health workers or volunteers involved in opioid overdose prevention efforts.
4. Family members or friends of individuals at risk for opioid overdose.

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What is PA Naloxone Administration Form - Cambria County?

The PA Naloxone Administration Form - Cambria County is a document used to report instances of naloxone administration, typically in cases of suspected opioid overdoses, to relevant health authorities in Cambria County.

Who is required to file PA Naloxone Administration Form - Cambria County?

Individuals or organizations that administer naloxone in response to an opioid overdose, including medical professionals, first responders, and trained laypersons, are required to file the form.

How to fill out PA Naloxone Administration Form - Cambria County?

To fill out the PA Naloxone Administration Form, provide information such as the date and time of administration, location, responder details, patient information, and outcome of the intervention.

What is the purpose of PA Naloxone Administration Form - Cambria County?

The purpose of the form is to collect data on naloxone usage, evaluate response efforts to opioid overdoses, and inform public health initiatives aimed at combating the opioid crisis.

What information must be reported on PA Naloxone Administration Form - Cambria County?

Information that must be reported includes the date and time of the naloxone administration, the address of the incident, the type of naloxone used, the identity of the person administering naloxone, demographic information of the patient, and the outcome post-administration.