Workplace Naloxone Incident Report Form

If you have a workplace naloxone program, you need to keep records of overdose incidents to document and review the effectiveness of your response efforts. Here’s a template incident report form that you can require authorized staff to complete each time they administer naloxone at your workplace.

Workplace Naloxone Incident Report

Authorized Staff Member: Date:
  1. When did the overdose happen (list month, day, year, time)?                                       [ ] Don’t know
  1. Where did the overdose happen?                                                                                          [ ] Don’t know
Yes No Don’t Know
3. Did somebody call 911?
4. Did first responders arrive?
5. Did somebody provide rescue breathing?
6. Did the patient survive?
7. How many doses of naloxone were administered?