Report for the Emergency Administration of Naloxone

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

Month Day Year
Time of Naloxone Administration: *

: Hour Minutes AM/PM Option
Route of Naloxone Administration *

Intranasal Auto-injectable Intramuscular Injection
Type of Person Emergency Medication Given to *

Student Staff Visitor
Approximate Age of Person Receiving Medication: *
Gender of Person Receiving Medication *

Male Female
Ethnicity of Person Receiving Medication

Yes, Spanish/Hispanic or Latino No, not Spanish/Hispanic or Latino
Race of Person Receiving Medication

American Indian/Alaskan Native African American Asian Native Hawaiian/Other Pacific Islander White
History of Opiate or Other Drug Abuse *

Yes No Unknown
Did this Person have a History of a Previous Naloxone Administration? *

Yes No Unknown
Was an Individual Health Plan in Place for this Person? *

Yes No Not a student
Vital Sign - BP:
Vital Sign - Pulse:
Vital Sign - Respirations:
Type of Substance that Triggered Event *

Orally Ingested Substance Inhaled Substance Injected Substance Unknown
If Know, Please List Specific Name of Medication/Substance:
Did Person Administer the Substance Prior to School?

Yes No Unknown
Location Where Symptoms Developed *

Classroom Cafeteria Health Clinic Restroom Bus
Please Describe How Exposure Occurred: *
Symptoms (Check All that Apply) *

Pale, Clammy Skin; Infrequent Speech; Very Shallow, Infrequent or No Breathing; Deep Snorting, Snoring or Gurgling; Unresponsive to Stimuli; Bradycardia; Cyanotic; Pinpoint Pupils;
Evidence or Suspicion of Overdose (Check All that Apply) *

Presenting Symptoms; History of Opioid or Other Illicit Drug Use; Report from Bystanders; School Nurse of Staff Prior Knowledge of Person; Nearby Medications, Illicit Drugs or Drug Paraphernalia; Signs of Previous Drug Injection Found on Skin;
Location Where Naloxone Administered *

Health Clinic Classroom Cafeteria Restroom Bus
Naloxone Administered By *

RN LPN Health Aide Non-licensed School Personnel Self-administered by Person
Naloxone Was

Student’s Own Naloxone Provided to the School by the Parent Staff or Visitor’s Own Naloxone Stock Naloxone Provided by the School
Location Naloxone Was Stored *

Health Clinic Carried by the Person Cabinet or Location Outside the Health Clinic
Time Elapsed Between Communication of Symptoms and Administration of Medication Was *

Less than 5 Minutes 5-10 Minutes 10-20 Minutes 20-30 Minutes 30-60 Minutes More than 60 Minutes
Was a Second Dose of Naloxone Required

Yes No Unknown
Symptoms of Opioid Withdrawal (Check All that Apply) *

Restlessness; Agitation or Irritability; Confusion; Body Aches; Diarrhea; Tachycardia; Fever; Runny Nose; Sneezing; Goose Bumps; Sweating; Yawning; Nausea or Vomiting; Nervousness; Shivering or Trembling; Abdominal Cramps; Weakness; Hypertension; None;
Was the Person Transported via EMS to a Local Medical Facility *

Yes If EMS was not Notified, Please Explain Why:
Explain Why, if EMS was not Notified:
Describe the Student/Staff/Visitor Outcome (Check All that Apply) *

Released from Medical Facility Within 24 Hours; Admitted to a Medical Facility for Observation and/or Treatment; Prescribed Naloxone by Medical Facility Provider; Follow Up Appointment Scheduled with Treatment Facility; Unknown;
Other Comments:
Name of Person Completing Form: *

First Name Last Name
Title of Person Completing Form *

RN LPN Health Aide Non-licensed School Personnel
Email of Person Completing Form: *

Confirmation Email
Created for Jolene Bracale on 03/27/2017
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