Narcan Use Report (Saratoga County, NY)

Use this form to report citizen or off-duty first responder use of Narcan

DO NOT USE this form if:

A Patient Care Report (PCR) was completed by fire or EMS
Fire or Law Enforcement gave the Narcan and a PCR was not completed (instead, click here for the public safety reporting form)

Question Title

* 1. What date was Narcan used?

Date

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* 2. If you know the zip code where the overdose happened, please enter it here:

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* 3. How many doses were administered?

3 or more

Unknown

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* 4. Did the person who overdosed survive?

Yes

Unknown

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* 5. Was 911 called?

Yes

Unknown

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* 6. Was rescue breathing performed before EMS, fire, or police arrived?

Yes

Unknown

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* 7. Were chest compressions (CPR) performed before EMS, fire, or police arrived?

Yes

Unknown

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* 8. What kind of place did the overdose happen?

Someone's home or apartment

Public place outside (like a park, sidewalk, yard)

Public place inside (like a car, restroom, bus, school, business)

Other (please specify)

Narcan Use Report (Saratoga County, NY)

Use this form to report citizen or off-duty first responder use of Narcan

Question Title

* 1. What date was Narcan used?

Question Title

* 2. If you know the zip code where the overdose happened, please enter it here:

Question Title

* 3. How many doses were administered?

Question Title

* 4. Did the person who overdosed survive?

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* 5. Was 911 called?

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* 6. Was rescue breathing performed before EMS, fire, or police arrived?

Question Title

* 7. Were chest compressions (CPR) performed before EMS, fire, or police arrived?

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* 8. What kind of place did the overdose happen?

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* 9. How old were they? (Use best guess)

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* 10. All information is anonymous and confidential. Please add any additional comments about this Narcan administration.