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* 1. Date of Call

Date

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* 2. Municipality of Call

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* 3. Gender

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* 4. Race / Ethnicity

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* 5. Administration of Dose #1

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* 6. Dose #1 Administered By

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* 7. Was an additional dose administered?

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* 8. Administration of Dose #2

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* 9. Dose #2 Administered By

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* 10. Was an additional dose administered?

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* 11. Administration of Dose #3

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* 12. Dose #3 Administered By

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* 13. Was an additional dose administered?

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* 14. Administration of Dose #4

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* 15. Dose #4 Administered By

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* 16. Status of Patient

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* 17. Disposition of Patient

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* 18. Name of Provider

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* 19. Certification of Provider (if applicable)

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* 20. Agency Due Replacements

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* 21. Did you leave behind any Narcan?   If so please include the # of doses and mg.   Example:  2 @ 4mg

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* 22. Additional Comments / Notes

0 of 22 answered
 

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