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Naloxone (Narcan) Distribution and Usage Form

  1. The purpose of this report is for the Merced County Department of Public Health to collect data about the distribution and usage of the Naloxone (Narcan) Nasal Spray, provided by the California Department of Public Health’s (CDPH) Naloxone Grant Program. The data collected will be used to support the continuation of the Naloxone Distribution Program.

  2. Instructions for Completing this Form:

  3. Step 1. The Local Entity will complete the top portion of this form to report to the Merced County Department of Public Health the dates of Naloxone distribution, the number of doses distributed and to what entities or programs received the doses.

  4. Step 2. The second portion of this form titled “Information Regarding the Overdose Experience” is to be used to document overdose events as information about these experiences becomes available.

  5. Step 1. Information Regarding Local Entity that received Naloxone from Merced County Department of Public Health

  6. (Do NOT provide names of individuals receiving Naloxone; Provide the TYPES of agencies, programs or other recipients that received the Naloxone please provide Organization name, type, location, and population served.)

  7. Step 2. Information Regarding the Overdose Experience

  8. Who Overdosed? (choose one):

  9. Gender of the Person Who Overdosed? (choose one):

  10. Transition

  11. Race/Ethnicity of the Person Who Overdosed? (choose all that apply):

  12. In What Setting did the Overdose Occur? (choose one):

  13. Do You Know What Drug Caused the Overdose?

  14. Was Naloxone Given During the Overdose?

    1. If Yes, Did it Work?

    2. If Naloxone Worked, How Long did it Take to Work?

    3. If Naloxone was Used, Provide the Reasons for its Use: (Choose all that apply)

    4. How did the Recipient Respond to Naloxone Administration?

    5. Naloxone was Administered By:

    6. Was the Recipient Conscious Before Administration of Naloxone?

      1. Was the Recipient Breathing Before Administration of Naloxone?

        1. If the Recipient was not Breathing, was Rescue Breathing Performed?

          1. Were Emergency Medical Services Contacted?

            1. Did You Stay with the Person Until the Naloxone Wore Off and/or the Recipient Received Medical Attention?

              1. Were Police, Firefighters, EMTs, or Paramedics Present?

                1. If Police, Firefighters, EMTs or Paramedics were Present, was the Interaction:

                  1. Did the Recipient go to a Hospital?

                    1. If the Recipient went to a Hospital, How was the Person Transported?

                    2. Did the Person Survive the Overdose?

                      1. Leave This Blank:

                      2. This field is not part of the form submission.