Get the free Naloxone Reporting Form

This form is to be filled out by officers of the University of North Alabama Police Department to report details regarding an overdose incident where naloxone was administered. It includes specific questions about the overdose circumstances, demographics of the individual, the drugs involved, and the effects of naloxone.

How to fill out naloxone reporting form

How to fill out naloxone reporting form

1. Begin by obtaining a copy of the naloxone reporting form from a reliable source.
2. Fill in your name and contact information in the designated fields.
3. Specify the date and time when naloxone was administered.
4. Indicate the location where the administration took place.
5. Provide details about the person who received naloxone, including age and gender.
6. Describe the circumstances under which naloxone was administered.
7. Document any symptoms exhibited by the individual prior to administration.
8. Record the dosage of naloxone that was given.
9. Include follow-up information on the individual’s condition after administration.
10. Review all entries for accuracy and completeness before submission.

Who needs naloxone reporting form?

1. Healthcare providers who administer naloxone for overdose situations.
2. Organizations involved in substance abuse prevention and intervention.
3. First responders, such as paramedics and police officers, who carry naloxone.
4. Local health departments monitoring opioid-related incidents.
5. Anyone involved in naloxone distribution programs.

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What is naloxone reporting form?

The naloxone reporting form is a document used to collect information regarding the distribution and administration of naloxone, a medication used to reverse opioid overdoses.

Who is required to file naloxone reporting form?

Health care providers, pharmacies, and organizations distributing naloxone are required to file the naloxone reporting form.

How to fill out naloxone reporting form?

To fill out the naloxone reporting form, individuals should provide details such as the quantity of naloxone distributed, the recipient's information, and the date of distribution.

What is the purpose of naloxone reporting form?

The purpose of the naloxone reporting form is to track naloxone distribution, assess its effectiveness, and monitor trends in opioid overdose prevention.

What information must be reported on naloxone reporting form?

The reporting form must include information such as the date of distribution, quantity of naloxone distributed, the setting (e.g., pharmacy, clinic), and recipient details.