Naloxone Administration Form 2026

1. Click ‘Get Form’ to open the Naloxone Administration Form in our editor.
2. Begin by entering the AGENCY NAME, followed by the TIME and DATE OF OVERDOSE. Ensure you select AM or PM appropriately.
3. Fill in the AGENCY INCIDENT NUMBER and specify the COUNTY where the overdose occurred, along with the CITY.
4. Provide details about the victim, including AGE, GENDER (select Male or Female), and their RESIDENCE information (City, State, Zip Code).
5. Indicate the RACE/ETHNICITY of the victim and whether they have received NALOXONE in the past by selecting Yes or No.
6. Check all suspected drugs involved in the overdose from the provided options. If applicable, specify any other drugs.
7. Document evidence secured during the incident, including descriptions of any drugs or paraphernalia found.
8. Detail how many doses of Naloxone were administered and by whom. Record how long it took for Naloxone to work and note the person's response.
9. Indicate whether the person survived and what happened next after revival. Fill in additional notes if necessary.
10. Finally, enter your name as a responder, sign and date it, and provide your contact phone number before submitting.

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