How many doses did you administer? Did the individual go to the hospital/emergency department? Where did the overdose take place? (check one) Yes Apartment/house No Healthcare facility School Did EMS provide care? Restaurant Yes Outdoor public space No Outdoor private space I don’t know Other: How recently did you attend an Overdose Response Training? Did the individual become conscious EMS arrived? before (check one) Yes, they became conscious minutes Within the past week I administered the first dose of Naloxone Within the past month Yes, they became conscious minutes 1-3 months ago after I administered the second dose of Naloxone 3-6 months ago No 6 months to 1 year ago Over 1 year ago Were police officers present? Which actions did you take to respond to the overdose? (check Yes all that apply) No Sternum rub Don’t know Called 911 or instructed someone else to call 911 Rescue breathing If yes, how would you describe the interaction? Chest compressions Positive Placed the person in recovery position Neutral Negative How confident did you feel in your ability to respond to the overdose? Additional information: How well do you feel your overdose training prepared you to respond? Did the individual survive? Yes No I don’t know Did the individual experience any side effects after Naloxone? (select all that apply) Vomited Had a seizure Felt sick/feelings of withdrawal Became None Other: Complete to the best of your ability and send to the Overdose Response Program at the Behavioral Health Administration by or fax: 410-402-8601.
How many doses did you administer? Where did the overdose take place? (check one) Apartment/house Healthcare facility School Restaurant Outdoor public space Outdoor private space Other: How recently did you attend an Overdose Response Training? (check one) Within the past week Within the past month 1-3 months ago 3-6 months ago 6 months to 1 year ago Over 1 year ago Which actions did you take to respond to the overdose? (check all that apply) Sternum rub Called 911 or instructed someone else to call 911 Rescue breathing Chest compressions Placed the person in recovery position How confident did you feel in your ability to respond to the overdose? How well do you feel your overdose training prepared you to respond? Did the individual survive? Yes No I don’t know Did the individual experience any side effects after Naloxone? (select all that apply) Vomited Had a seizure Felt sick/feelings of withdrawal Became None Other: Did the individual go to the hospital/emergency department? Yes No Did EMS provide care? Yes No I don’t know Did the individual become conscious before EMS arrived? Yes, they became conscious minutes I administered the first dose of Naloxone Yes, they became conscious minutes after I administered the second dose of Naloxone No Were police officers present? Yes No Don’t know If yes, how would you describe the interaction? Positive Neutral Negative Additional information: Complete to the best of your ability and send to the Overdose Response Program at the Behavioral Health Administration by or fax: 410-402-8601.
BHA%20Naloxone%20Use%20Report%20rev%202-16%20(2).docx