NYSDOH Opioid Overdose Prevention Initiative

Community Naloxone Usage Form

Purpose: This form is to serve as a collection tool for program staff. Program staff are required to enter the information into the NYSDOH Opioid Overdose Prevention Program System’s electronic DOH sanctioned form.

On what day was the naloxone used?

If naloxone was used on more than one day, please submit a separate report for each use. If you don’t know the precise date, choose one that you think is close.

Zip Code: Do you know the zip code where the overdose happened?

County/Borough & Town

Did the person who overdosed survive?

Yes

Don't know

Please select the type of naloxone used.

Check all that apply.

Narcan™ Nasal spray (4mg)

Intramuscular injection generic

Nasal spray generic (2mg)

Don't Know

How many doses of naloxone were administered?

Was 911 called? (choose one)

Yes

Don't know

How old were they? (best guess)

What was the perceived sex of the individual who received assistance?

Male

Female

Unknown Sex

What was the perceived race of the individual who received assistance? Select all that apply.

African- American/Black

Asian/Pacific Islander

Hispanic/Latino(a)

Native American

White

Unknown race/ethnicity

Other

In what kind of place did the overdose happen?

Someone's home or apartment

Shelter or in a supportive housing setting

Public place outside (e.g. park; sidewalk, yard)

Public place inside, other than a library, secondary school, or college/university/trade school campus (e.g. restroom, business, train, car)

Library

Secondary school (e.g. high school, middle school)

On a college/university/trade school campus

Other

Please add any additional comments about this naloxone administration.

Thank you for taking the time to complete this form. All program data submitted are confidential.
If you have any questions, please email overdose@health.ny.gov or call 1-800-692-8528.