New York State Center for School Health - School Reporting Form for Opioid Overdose Survey

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* 1. Date of form submission

Date

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* 2. School information

School Name

School District

School Street

City/Town

ZIP Code

Phone Number

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* 3. County

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* 4. Type of school

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* 5. Date of naloxone administration

Date

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* 6. Time of naloxone administration

During school hours

During school sponsored event

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* 7. Naloxone was administered by

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* 8. Gender of naloxone recipient

Male

Female

Transgender

Unknown

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* 9. Race of naloxone recipient (check all that apply)

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* 10. Age of naloxone recipient

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* 11. Naloxone recipient was a

Student

Staff Member

Other (please specify)

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* 12. Drug(s) used by naloxone recipient at time of overdose (check all that apply)

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* 13. Administration of naloxone

	Yes	No	Unknown
Was the recipient conscious before administration of naloxone?	Was the recipient conscious before administration of naloxone? Yes	Was the recipient conscious before administration of naloxone? No	Was the recipient conscious before administration of naloxone? Unknown
Was the recipient breathing before administration of naloxone?	Was the recipient breathing before administration of naloxone? Yes	Was the recipient breathing before administration of naloxone? No	Was the recipient breathing before administration of naloxone? Unknown
Was rescue breathing performed?	Was rescue breathing performed? Yes	Was rescue breathing performed? No	Was rescue breathing performed? Unknown
Was a second dose of naloxone given?	Was a second dose of naloxone given? Yes	Was a second dose of naloxone given? No	Was a second dose of naloxone given? Unknown
Was an automated external defibrillator used?	Was an automated external defibrillator used? Yes	Was an automated external defibrillator used? No	Was an automated external defibrillator used? Unknown
Was Emergency Medical Services contacted?	Was Emergency Medical Services contacted? Yes	Was Emergency Medical Services contacted? No	Was Emergency Medical Services contacted? Unknown
Did the recipient go to the hospital?	Did the recipient go to the hospital? Yes	Did the recipient go to the hospital? No	Did the recipient go to the hospital? Unknown
Did the recipient survive?	Did the recipient survive? Yes	Did the recipient survive? No	Did the recipient survive? Unknown

Please include any information you believe would be helpful in describing the overdose prevention incident.

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* 14. NYSDOH requires review by both the School Medical Director and Program Director/Designee. Overdose prevention incident was reviewed by:

School Medical Director

Date

Program Director/Designee

Date

To submit this form:
1 . Hit Ctrl + P on your keyboard to print a copy of this submission form.
2. Press the "Done" button below.
3. Share this report with you Clinical Director
4. A copy of this report should be sent to the NYSDOH by fax: or mail