Narcan Utilization Log

Please complete the information below following utilization of your Narcan kit. All information is confidential, and will be aggregated and utilized for ongoing education and services.

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* 1. Was Narcan (naloxone) administered?

Yes

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* 2. If yes, how many doses were utilized?

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* 3. Date of Utilization

Date / Time

Date

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* 4. Location of utilization

Private Residence

Hotel/Motel

Shelter

Sidewalk or Street

Nursing Home or Assisted Living

Other (please specify)

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* 5. What happened after Narcan was administered?

Person woke up

Person vomited

Person went/transported to hospital

I am not sure what happened

Person did not wake up from the overdose or died

Decline to answer

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* 6. Please list the serial number(s) of the Narcan kits administered.

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* 7. Any CKF staff or Peer Mentor follow up requested?

Yes

If yes, please enter contact information here: