Policy Text
KERN COUNTY SHERIFF'S OFFICE
NALOXONE DEPLOYMENT REPORTING FORM
Assignment : Case #:
Date of Overdose: Time of Overdose: hours Victim Contact Time: hhoouurrss
Victim's Name: Victim's Date of Birth: Victim's Age:
Race Ethnicity: White Black Hispanic Asian Indian American Indian Pacific Islander Other
Gender of the person who overdosed: Male Female Unknown
Address where overdose occurred (including Zip Code)
SIGNS OF OVERDOSE PRESENT
(Check all that apply)
Unresponsive Respirations <8 min. Not Breathing Blue lips Pinpoint Pupils
Slow pulse No pulse Drug paraphernalia Located Blue nails
DETAILS OF NALOXONE DEPLOYMENT
Time Naloxone was given: hours Number of doses: Did Naloxone work: Yes No Not sure
If yes, how long did it take to work: < 1 min 1-3 min 3-5 min >5 min Don't know
Patients response to Naloxone: Responsive and alert Breathing improved No response to Naloxone
Post Naloxone withdrawal symptoms: None Irritable or Angry Combative Vomiting
(Check all that apply) Other (Specify):
Did the person survive?