Narcan Usage Report Question Title * 1. On what date was the Narcan used (approximate if unsure) Date Date Question Title * 2. Zip code where the Narcan was used Question Title * 3. Did the person who overdosed survive? Yes No I do not know Question Title * 4. How many Narcan doses were used? One dose of 4MG Nasal Spray Two Doses of 4 MG Nasal Spray Other (please specify) Question Title * 5. Did anyone else give Narcan, if so who? Emergency Responders (EMT) Police Fire Dept Additional bystander No, Nobody else did I do not know Question Title * 6. Did you or someone else call 911? Yes No I do not know Question Title * 7. Did you or anyone at the scene perform CPR or Rescue breathing, if yes, who? Emergency Responder (EMT) Police Firefighter I (the trained overdose responder) did Nobody did, the person could breathe I do not know Other (please specify) Question Title * 8. How old was the person that overdosed? (Best guess) Question Title * 9. Do you know the person's gender? Male Female Transgender or non conforming Unknown Question Title * 10. Do you know the person's race? African American Asian/Pacific Islander Hispanic/Latino Native American White More than one race Unknown Other (please specify) Question Title * 11. Do you know what substances the person who overdose was likely to have used: Fentanyl Heroin Pain Medication (Hydrocode, oxycodone, Vicodin, etc.) Cocaine (with fentanyl) Methadone I do not know Other (please specify) Question Title * 12. In what type of location did the overdose happen? (i.e. public store, private home, public street, public bathroom etc. ) Public outside space Public business Public bathroom Private home Public shelter Supportive living Corrections Center (jail, prison etc.) Rehabilitation Center (inpatient or outpatient rehab facility) Other (please specify) Question Title * 13. Do you know where the Narcan given to the person was from? Kit was from Prevention Network Training Kit was from a Prevention Network OOPP (Opioid Overdose Prevention Program) Narcan box Kit was a Refill Kit from Prevention Network Other (please specify) Question Title * 14. If you are comfortable, can you share the location of the Narcan box where you got your kit? Rescue Mission, Syracuse NY (Dickerson St) Prevention Network New Journey Wellness Center, Syracuse NY CARES Covid19 Responders/Joe Family Foundation, Syracuse NY North East Community Center, Syracuse NY Liberty Resources, Syracuse NY On Care Family Health, Cicero NY I DID NOT GET MY NARCAN FROM A NARCAN BOX Question Title * 15. What is the relationship between the person who overdosed and the trained responder? *for Data use only, not tied to the responder in any way. None, they were a stranger Friend Family Member Partner co-worker client/patient Prefer not to answer stranger, but connected to them through responder's work (i.e. corrections officer and person incarcerated) Other (please specify) Question Title * 16. Has this person experienced an overdose in the past? Yes No I do not know Question Title * 17. Was a replacement kit given? If you need one, please contact jmccarthy@preventionnetworkcny.org and select yes. Yes No I do not know Question Title * 18. Please add any additional comments about this naloxone administration here: Question Title * 19. Thank you for taking the time to complete this form. All program data submitted are confidential. If you have any questions, please email jmccarthy@preventionnetworkcny.org or call 315-471-1359. If you need a replacement kit, enter your email in this text box and we will contact you. If you are comfortable leaving your name and address, please enter in the box and we will mail you a refill kit. Done
