Naloxone Deployment Reporting Form

NJ Attorney General's Heroin & Opiates Task Force
Naloxone Deployment Reporting Form
Police Department:
Case #:
Date of Overdose:
/
/
Time of Overdose:
Location where overdose occurred: (Street address, City)
Gender of the victim:
Race/Ethnicity
AM
Female
Black
PM
Address of victim:6WUHHWDGGUHVV&LW\
Male
White
:
Hispanic
Unknown
Asian/Indian
Age:
American Indian
Pacific Islander
Signs of overdose present (check all that apply)
Unresponsive
Breathing Slowly
Not Breathing
Slow pulse
No pulse
Other (specify):
Suspected overdose on what drugs
Heroin
Benzos/ Barbituates
Alcohol
Methadone
Blue lips
(check all that apply)
Cocaine/ Crack
Any other opioid
Suboxone
Don’t Know
Other (specify):
Evidence
Heroin
Stamp (Text/Color)
Describe Image:
Stamp (Text/Color)
Describe Image:
Opiate Pills
Evidence Secured
Pill Type:
Doctor's Name:
Paraphernalia
Drugs
Details of Naloxone Deployment
Number of doses used:
Did Naloxone work:
If yes, how long did it take to work:
Patient’s response to Naloxone
<1 min
Yes
No
1-3 min
Responsive and alert
Post-Naloxone withdrawal symptoms (check all that apply)
3-5 min
None
Sternal Rub
Recovery position
Yelled
Shook them
EMS Naloxone
Bystander Naloxone
Other (specify):
Care transfer to EMS
Naloxone Information:
No response to Naloxone
Physically Combative
Yes
Rescue breathing
Automatic Defibrillator
Disposition:
Don’t Know
Irritable or Angry
Did the person live:
Other (specify):
What else was done:
>5 min
Responsive but sedated
Dope sick (e.g. nauseated, muscle aches, runny nose, and/or watery eyes)
Vomiting
Not Sure
No
Chest compressions
Oxygen
Other (specify):
Lot #:
Expiration date:
/
/
Notes / Comments
Officer’s Name
Signature
Date of Report
Please email form to roicadmin@gw.njsp.org and MarjorieGibbons@co.ocean.nj.us or
fax to NJROIC (609) 530-3650 and (732) 506-5088.