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.

Date:*

Time (24 hour format):*

Reporting agency:*

Reporting officer's name:*

Incident number:*

Incident address:*

Incident city:*

Responding fire department identifier:*

Responding ambulance identifier:*

Initial Assessment

Was the patient awake?*

Yes

No

Was the patient breathing?*

Yes

No

Approximate Breaths per Minute:*

Was the patient's speech clear?*

Yes

No

Treatment Provided

Did you reposition the patient's airway?*

Yes

No

Did you administer rescue breaths?*

Yes

No

Was CPR performed?*

Yes

No

Was naloxone administered?*

Yes

No

Total doses of naloxone administered*

Other treatment provided:

Assessment After Treatment

Did patient's respirations improved?*

Yes

No

Approximate breaths/ minute after treatment:*

Did patient wake up?*

Yes

No

If patient woke up, was their speech clear?:*

Yes

No

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