DuPage NARCAN Program (DNP) Community Use Log
Date of use
*
-
Month
-
Day
Year
Date
Where were you trained?
*
360 Youth Services
Banyan Treatment Center
Bensenville Public Library
DuPage County Health Department
Hinsdale-Bystander
Overdose Awareness Day
Northwestern Medicine - Central DuPage Hospital
Milton Township CERT
Lisle-Woodridge Community Training
Other
Number of doses used
*
Please Select
1
2
3
4
5
6
7
8
9
Unknown
Town Where Narcan Was Used:
*
Location:
*
Please Select
House/apartment
House
Apartment
Motel
Business
Parking Lot
Vehicle
Train
Park
School
Jail
Street
Other
Closest Cross Street
Zipcode
County
*
What was the victim's sex?
*
Male
Female
Transgender
Other
What was the victim's race?
*
African American/Black
Asian/Pacific Islander
Hispanic/Latino
Native American
White/Caucasian
Unknown
What was the victim's age (estimated)?
*
18 or less
19-29
30-39
40-49
50-59
60 or more
Unknown
Specific Age:
Drug
*
Inject Heroin
Sniff Heroin
Swallow Heroin
Smoke Heroin
Use Heroin, But How is Unknown
Fentanyl
Methadone
Cocaine
Benzos
Cannabis
Alcohol
Pain Pills : Specify below if known
Amphetamine
Unknown
Other
Was the victim conscious before naloxone was used?
Please Select
Yes
No
Other Actions Taken:
Rescue Breathing
Chest Compressions
Sternal Rub
Recovery Position
Called 911
None Indicated
Heroin/Opiate use confirmed?
Please Select
Yes
No
Did victim survive?
Please Select
Yes
No
Was naloxone ever given in the past?
Please Select
Yes
No
Unknown
Did victim go to the hospital?
Please Select
Yes
No
Refused
If Yes, name of hospital (if known):
Save (Was the victim's saved from an overdose with naloxone)?
*
Yes
No
DNP Use #
DNP Save #
Additional Comments
Submit
Should be Empty: