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Naloxone Use & Incident reporting Form

Please use this form to report all incidents including those that do not involve Naloxone.

 

In the case of death or serious incident please complete this form and submit within 1-2 working days.

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Type of Incident

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11.  

Gender

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Review of Incident

22.  

Is client in treatment?

23.  

Has treatment key worker been informed? 

24.  

Has a review taken place? If in treatment/involved with other agencies – has a joint review taken place?

26.  

Naloxone replaced

27.  

Naloxone training offered