Law Enforcement Naloxone Administration Reporting Form

 

San Mateo County Law Enforcement Naloxone Reporting

Please use this form to provide timely and pertinent information regarding an event of naloxone administration by a San Mateo County law enforcement agency. The information submitted should originate from the officer(s) involved. All submitted information is and will remain confidential. NALOXONE ADMINISTRATION MUST BE REPORTED WITHIN 48 HOURS. Please complete and submit this form or print/scan/email the completed form to ems@smcgov.org. Please do NOT provide any protected health information (e.g., name, date of birth, or social security number of an EMS patient) with your submission. An event number or date and address of the event will be sufficient. If you have questions or concerns, please contact the EMS Duty Officer through Public Safety Communications.

 

 
 
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Initial Assessment

 
 
 
 
 

 

Treatment Provided

 
 
 
 
 
 
 

 

Assessment After Treatment