Narcan Reporting for Schuylkill County Effective 04/01/20 Question Title * 1. Date of Call Date Date OK Question Title * 2. Municipality of Call OK Question Title * 3. Gender Male Female Transgender Unknown OK Question Title * 4. Race / Ethnicity White / Caucasian Black / African American Hispanic Latino Asian / Pacific Islander Other (please specify) OK Question Title * 5. Administration of Dose #1 4mg 2mg OK Question Title * 6. Dose #1 Administered By Police Fire / QRS EMS Bystander OK Question Title * 7. Was an additional dose administered? Yes No OK Question Title * 8. Administration of Dose #2 4mg 2mg OK Question Title * 9. Dose #2 Administered By Police Fire / QRS EMS Bystander OK Question Title * 10. Was an additional dose administered? Yes No OK Question Title * 11. Administration of Dose #3 4mg 2mg OK Question Title * 12. Dose #3 Administered By Police Fire / QRS EMS Bystander OK Question Title * 13. Was an additional dose administered? Yes No OK Question Title * 14. Administration of Dose #4 4mg 2mg OK Question Title * 15. Dose #4 Administered By Police Fire / QRS EMS Bystander OK Question Title * 16. Status of Patient Alive Deceased OK Question Title * 17. Disposition of Patient EMS Transported Patient Refusal Other (please specify) OK Question Title * 18. Name of Provider OK Question Title * 19. Certification of Provider (if applicable) OK Question Title * 20. Agency Due Replacements OK Question Title * 21. Did you leave behind any Narcan? If so please include the # of doses and mg. Example: 2 @ 4mg OK Question Title * 22. Additional Comments / Notes OK SUBMIT