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

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