Quarterly Pharmacy Naloxone Dispensing Report

For Naloxone Non-Patient Specific Prescription and Dispensing Protocol

Submit number of DOSES of each naloxone formulation/product dispensed to DOHMH at the end of the month following the close of each quarter.

Reporting period (One per report) Report Due By
 Jan. 1 - March 31 April. 30
 April 1 - June 30 July 31
 July 1 - Sept. 30 Oct. 31
 Oct. 1 - Dec. 31 Jan. 31


Please provide dispensing information for each naloxone formulation in actual DOSES (not scripts/boxes):

1) NARCAN® (4MG/.1ML; NDC: 69547-353-02) ) – Please note Narcan® contains TWO doses per box.


2) INTRAMUSCULAR (IM) (0.4MG/ML; NDC 00409-1215-01 OR NDC 67457-0292-02)


3) EVZIO® (0.4MG/ML; NDC 60842-030-01) – Please note Evzio® contains TWO DOSES per box.


4) MULTI-STEP INTRANASAL (IN) (1MG/ML; NDC 76329-3369-01)


Please submit a Reversal Reporting Form for any reversals reported using naloxone.