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Naloxone Use & Incident reporting Form

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.

Name of Project

* required*

Maximum 255 characters

0/255

Reporting Officer

Maximum 255 characters

0/255

Date of Incident

* required*

Date reported to DAAT

Date reported to We Are With You

Type of Incident

Death

Overdose (using Naloxone)

Overdose (without Naloxone)

Theft of Kit

Issued at request of WAWY telephone prescription

Other e.g serious alcohol incident etc (please specify)

Number of kits used (if applicable)

Maximum 255 characters

0/255

Expiry date and Batch number (if applicable)

Maximum 20,000 characters

0/20,000

10.

Initials of casualty

Maximum 255 characters

0/255

11.

Sex

Male

Female

Non-binary

Transgender

Other

12.

Age of casualty

Maximum 255 characters

0/255

13.

Time Naloxone administered (if applicable)

Maximum 255 characters

0/255

14.

Dose administered (if applicable)

Maximum 255 characters

0/255

15.

Time ambulance called

Maximum 255 characters

0/255

16.

Time ambulance arrived

Maximum 255 characters

0/255

17.

How many overdoses in the past 12 months

Maximum 255 characters

0/255

18.

Details of incident

Maximum 20,000 characters

0/20,000

19.

Initials and identification of those involved (i.e. resident, staff, visitor)

Maximum 20,000 characters

0/20,000

20.

Action taken in response to incident (including ambulance called, police attended etc)

Maximum 20,000 characters

0/20,000

21.

Outcome of incident (including if client survived; was conveyed to hospital)

Maximum 20,000 characters

0/20,000

Review of Incident

22.

Is client in treatment?

Yes

Don't know

23.

Has treatment key worker been informed?

Yes

Don't know

24.

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

Yes

25.

Date of review

26.

Naloxone replaced (if applicable)

Yes

N/A

27.

Naloxone training offered

Yes

N/A

28.

Any other comments

Maximum 20,000 characters

0/20,000

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