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    • Narcan® Utilization Report

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

     

    Narcan® Utilization Report

    "*" indicates required fields

    Today's Date*
    Your Name*
    Date of Overdose
    Time of Overdose
    :
    Location of Overdose
    Age of Victim
    Gender of Victim
    Race/Ethnicity of Victim
    Name of Victim
    Address of Victim
    Did Naloxone work?*
    If yes, how long did it take to work?
    Did victim survive?*
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