Opioid Antagonist (like Naloxone/Narcan) Administration Report

9 b. Is this student from your school?

9 bi. What school is this student from?

9 c. What grade were they in when it was administered?* 
If this happened after the end of one school year but before the next, classify as the grade the student would be starting in the coming school year.

10 a. Do you know the age of the person?

10 b. Age of person who received the opioid antagonist
Specify age in years at the time the opioid antagonist was administered

11. The following are statements about someone's sex, assigned sex at birth, and intersex status*

Check all that apply for this patient

12 a. Please select the gender identity that best describes this patient*

12 b. Is this patient transgender or of transgender experience

13. Race/Ethnicity*

Please select all races/ethnicities that describe this patient

14 a. Has this person received an opioid antagonist previously during this academic year at school?

14 b. Before this incident you're reporting, during how many incidents were opioid antagonists administered to this person at school this school year?

15 a. Symptoms prior to administration of the opioid antagonist*

Select all that apply

15 a. Please describe

Do not include anyone's name

15 b. Location where symptoms developed
Select the option that best describes the location.

16 a. Was this administered due to a suspected overdose?*

16 b. How did overdose occur?
Please provide as many details as possible about the type and nature of the exposure, including source of exposure.
Do not include anyone's name

16 b. Please explain why this dose was administered, since it is not suspected to be due to overdose*

Do not include anyone's name

17 a. TOTAL number of doses administered (including the first) by school personnel (nurse, teacher, student, staff, etc)*

17 b. Were any of the doses administered expired?

17 b. Why was expired medication administered?
Do not include anyone's name

18 a. Date the FIRST or only dose of opioid antagonist was administered for this incident*
Click the icon to display a calendar, then select the date from the calendar.

18 b. What time was this FIRST or only dose administered?

18 bi. How long was it between identification of the person suspected of experiencing an opioid overdose and administration of the FIRST or only dose of an opioid antagonist?*

18 bi. Please explain or comment since this was a prolonged period (greater than 5 minutes)*
Do not include anyone's name

18 c. Which medication was administered in this FIRST or only dose?*

18 d. Which was the route of administration for this FIRST or only dose?*

18 e. What was the dose of this FIRST or only administration?*

18 f. Where was the FIRST or only dose of opioid antagonist stored?*

18 g.  Person type that administered/gave the FIRST or only dose of opioid antagonist*

Select all that apply  

18 h. Where was the patient when this FIRST or only dose was administered?*

18 i. Where was/were the subsequent dose(s) (dose(s) other than the first dose) of opioid antagonist stored? *

Select all that apply 

18 j. Person type that administered/gave the subsequent dose(s) (dose(s) other than the first dose) of opioid antagonist*

Select all that apply  

18 k. Which medication(s) was/were administered in the subsequent dose(s) (dose(s) other than the first dose) *

Select all that apply

18 l. Select route of administration that was used for subsequent dose(s) (dose(s) other than the first dose) *

Select all that apply

18 m. Tell us about the subsequent doses (dose(s) other than the first dose) that were given

• medication name
• route of administration
• dose
• where the dose(s) came from
• the order in which they were administered

Do not include anyone's name

18 n. Did you see Emergency Medical Services (EMS) give any doses of Opioid Antagonist?*

19. Was rescue breathing (either with or without CPR) administered?*

20. Was CPR initiated? *

21. Disposition when they left the school property or event? *

22 a. Was the person transferred to the ER?*

22 b. Since they were transferred to an ER, how was the person transferred?

22 c. Discharged after this amount of time had passed:

22 d. Was the patient declared deceased after the transfer of care to EMS? *

23. Patient Outcome
Do not include anyone's name

24 a. Does the school have stock/undesignated opioid antagonist available for emergency use?*

24 b. In what form is the school's stock opioid antagonist available?*
Select all that apply

24 c. Location of opioid antagonist stock
Select all that apply

25 a. Was each person who administered opioid antagonist(s) formally trained in accordance with the standards established by the Department, outlined in 105 CMR 210.011(A)(4)(a) ?

25 b. Please specify who was not formally trained

Please share their staff position or other relevant position descriptor (such as student or parent).

Do not include anyone's name

26 a. Is there a written school policy on management of suspected overdose in place?

26 b. Were the school policies followed?

26 c. Why were school policies not followed?*

Do not include anyone's name

27. Does this school/district have an approved Medication Controlled Substance Registration (MCSR) with DPH per 105 CMR 210?

28. Did a debriefing meeting occur?

29 b. Comments about recommendations for change

Do not include anyone's name

30. Did you submit an earlier version (or a partially completed version) of this report previously? 

This information helps us identify duplicate reports.