Monthly Narcan Reporting

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This form must be reported to the state monthly. Please answer the questions as accurately as you are able to.

Date Narcan was used *

YYYY

Name of individual who administered *

How were we called to the scene? *

What was the setting of the incident? *

# of units of Narcan administered to a single person? *

What substance was consumed prior to the overdose? *

What was the outcome for the individual? *

Patient's race? *

Patient's age? (If unknown, give an estimate) *

Patient's gender? *

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