Get the free Naloxone Administration Report Form MSDE School ...

Report of Naloxone Administration Student Demographics and Health History School District: ___ Name of School: ___ StudentAge:___ Type of Person:Ethnicity: Spanish/Hispanic/Latino: Race:StaffYesVisitorGender:MFTransgenderNoAmerican

How to fill out naloxone administration report form

How to fill out naloxone administration report form

1. Obtain a naloxone administration report form from your organization or healthcare provider.
2. Fill in the date and time of the naloxone administration.
3. Record the location where the administration took place.
4. Provide details about the individual who received naloxone, including name, age, and any known medical history.
5. Document the circumstances leading to the naloxone administration, including signs of opioid overdose.
6. Indicate the dosage of naloxone administered and the route of administration (e.g., intranasal or intramuscular).
7. Include any follow-up actions taken after administering naloxone, such as calling emergency services.
8. Sign and date the form to verify that the information provided is accurate.

Who needs naloxone administration report form?

1. Healthcare professionals who administer naloxone in emergency situations.
2. Organizations and agencies that provide naloxone training and distribution.
3. First responders and community members who have received naloxone training.
4. Individuals who have witnessed an overdose and administered naloxone.

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What is naloxone administration report form?

The naloxone administration report form is a document used to record details about the administration of naloxone, a medication used to reverse opioid overdoses.

Who is required to file naloxone administration report form?

Emergency responders, healthcare providers, and organizations that distribute or administer naloxone are typically required to file this report form.

How to fill out naloxone administration report form?

To fill out the form, provide information such as the date and time of administration, the individual receiving naloxone, the dose given, any additional actions taken, and the outcome of the intervention.

What is the purpose of naloxone administration report form?

The purpose of the form is to document instances of naloxone use, track effectiveness, and gather data to improve responses to opioid overdoses and public health strategies.

What information must be reported on naloxone administration report form?

Information that must be reported includes the date and time of naloxone administration, the location, individual's age and gender, the amount of naloxone used, and the response observed after administration.