Report for the Emergency Administration of Naloxone

Report for the Emergency Administration of Naloxone
Name of County:*
Date of Naloxone Administration:*

MonthDayYear
Route of Naloxone Administration*

IntranasalAuto-injectableIntramuscular Injection
Type of Person Emergency Medication Given to*

StudentStaffVisitor
Approximate Age of Person Receiving Medication:*
Gender of Person Receiving Medication*

MaleFemale
Type of Substance that Triggered Event*

Orally Ingested SubstanceInhaled SubstanceInjected SubstanceUnknownOther
Location Where Naloxone Administered*

Health ClinicClassroomCafeteriaRestroomBusOther
Naloxone Administered By*

RNLPNHealth AideNon-licensed School PersonnelSchool Resource OfficerSelf-administered by PersonOther
Location Naloxone Was Stored*

Health ClinicCarried by the PersonOther
Was a Second Dose of Naloxone Required*

YesNoUnknown
Was the Person Transported via EMS to a Local Medical Facility*

YesNo
If EMS was not notified, please select the reason: (check all that apply)*

Assessed, treated, symptoms resolved, and returned to classHome with parentTaken to healthcare provider by parentTransported to Emergency Medical Services (EMS) by parentParent refused EMS transportOther
Explain Why, if EMS was not Notified:
Title of Person Completing Form*

RNLPNHealth AideNon-licensed School PersonnelOther
Created for Jolene Bracale on 03/27/2017
Should be Empty: