Form Center

2. Date:
3. Time:
4. Check one:

   1. AM
   2. PM
6. Location:
8. Patient Age:
9. Sex:
   -- Select One --MaleFemaleOther
10. Responsive on EMS Arrival?

    1. Yes
    2. No
12. Narcan Given?

    1. Yes
    2. No
13. If Yes, Who Administered the Narcan?

    1. EMS
    2. Bystander
15. Number of Doses:
16. Response to Narcan:

    1. Improved
    2. No Change
18. Suspected Substance(s):

    1. Opioids
    2. Stimulants
    3. Alcohol
    4. Unknown
    5. Other
19. If Other, Explain:
21. Transported to Hospital:

    1. Yes
    2. No
22. Leave Behind Kit Given?

    1. Yes
    2. No
23. Scene Evidence (Optional):

    1. Paraphernalia
    2. Pills
    3. Syringes
    4. None
25. Additional Details/Comments:
27. EMS Agency Name:
Leave This Blank:


29. Submit

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