🚨 Part 1: Incident Details & Initial Observations

1. Time of incident:

_______ : _______ AM / PM

2. Location of incident:

3. Initial signs observed (check all that apply):

Unconscious or unresponsive

Slow or absent breathing

Blue lips or fingernails

Gurgling sounds

Cold, clammy skin

Pinpoint pupils

4. Was the person responsive to verbal commands?

Yes, fully responsive

Partially responsive

No response

💉 Part 2: Naloxone Administration

5. Time naloxone was administered:

_______ : _______ AM / PM

6. Type of naloxone used:

Nasal spray (Narcan)

Auto-injector

Other: _______________

7. Number of doses given:

1 dose

2 doses

3 or more doses

8. Response time after first dose:

Person responded after _______ minutes

9. Emergency services called:

Yes, before naloxone

Yes, after naloxone

No

📋 Part 3: Follow-up & Conclusions

10. Person's condition after naloxone administration:

Fully conscious and alert

Conscious but confused

Partially responsive

No improvement

11. Additional actions taken (check all that apply):

Placed in recovery position

Monitored breathing continuously

Stayed with person until EMS arrived

Provided emotional support

Secured the scene

12. Overall assessment of response effectiveness:

Success Criteria:

I can identify signs of opioid overdose ✓

I can describe proper naloxone administration steps ✓

I can document emergency response actions clearly ✓

Naloxone Administration Report Template

Naloxone Administration Report Template

🚨 Part 1: Incident Details & Initial Observations

💉 Part 2: Naloxone Administration

📋 Part 3: Follow-up & Conclusions

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