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Narcan® Utilization Report

This form is to report used Narcan® provided by the Council on Chemical Abuse.

Narcan® Utilization Report

Today's Date*
Month
Day
Year
Your Name*
First Last
Email
Phone
Date of Overdose
Month
Day
Year
Time of Overdose

: Hours

Minutes

AM/PM
Location of Overdose
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Age of Victim
- Less than 18
- 18-30
- 31-45
- 46-65
- More than 65
Gender of Victim
- Male
- Female
- Other
- Unsure
Race/Ethnicity of Victim
- American Island or Alaskan Native
- Asian
- Black
- Hispanic
- Pacific Islander
- White
Name of Victim
First Last
Address of Victim
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Number of Doses Used*
Did Naloxone work?*
- Yes
- No
- Unsure
If yes, how long did it take to work?
- Less than 1 minute
- 1-3 minutes
- 3-5 minutes
- More than 5 minutes
- unsure
Did victim survive?*
- Yes
- No
- Unsure
Naloxone Lot #*
Naloxone Expiration Date*
Notes/Comments

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