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Pharmacy Overdose Reversal Reporting Form
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Pharmacy Overdose Reversal Reporting Form
For Naloxone Non-Patient Specific Prescription and Dispensing Protocol
*
Indicates required fields
Pharmacy Name
*
Supervising Pharmacist
*
Pharmacy Address
*
Contact Phone
*
Contact Email
*
Pharmacist Submitting Form
Date Submitted
*
(approximate date is sufficient)
Describe reported overdose reversal/naloxone use
*
Yes
No
What type of naloxone was used?
Intramuscular
Intranasal
Auto-injector
How many doses of naloxone were used?
One
Two
More than two
On what date was naloxone used?
(approximate date is sufficient)
Where was naloxone used?
(Borough/Neighborhood/Cross-Streets/ZIP)
Was 911 called when the person overdosed?
Yes
No
I don't know
Did the person survive?
*
Yes
No
I don't know
Please share any other information about the event
Please check "I'm not a robot" below to verify you are a person.
Submit