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NYSDOH Opioid Overdose Prevention InitiativeCommunity Naloxone Usage FormPurpose: This form is to serve as a collection tool for program staff. Program staff are required to enter the information
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How to fill out community naloxone usage form
How to fill out community naloxone usage form
01
Obtain a copy of the community naloxone usage form from a local health department or organization.
02
Carefully read and review the instructions provided on the form.
03
Fill out personal information such as name, contact information, and any relevant medical history.
04
Provide information about any previous training or experience with naloxone administration.
05
Indicate any allergies or sensitivities to medications.
06
Sign and date the form to confirm accuracy and consent.
07
Return the completed form to the designated individual or organization for processing.
Who needs community naloxone usage form?
01
Individuals who are at risk of witnessing an opioid overdose.
02
Healthcare professionals who may need to administer naloxone in an emergency situation.
03
Community members who want to be prepared to help save a life in the event of an overdose.
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What is community naloxone usage form?
Community naloxone usage form is a document used to report the administration of naloxone in a community setting.
Who is required to file community naloxone usage form?
Healthcare providers, first responders, and other individuals or organizations involved in naloxone administration are required to file the community naloxone usage form.
How to fill out community naloxone usage form?
Community naloxone usage form can be filled out by providing information such as the date, time, location, and dosage of naloxone administration, as well as the individual receiving the naloxone.
What is the purpose of community naloxone usage form?
The purpose of community naloxone usage form is to track the use of naloxone in community settings and gather data to assess the effectiveness of naloxone distribution programs.
What information must be reported on community naloxone usage form?
Information such as the date, time, location, dosage of naloxone administered, and details of the individual receiving the naloxone must be reported on the community naloxone usage form.
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