Use of Naloxone (Narcan) Reporting Form Please complete the questions below as soon as possible following the use of Naloxone Nasal Spray Date of overdose (mm/dd/yyyy) *Zip Code or CityWhat signs was the patient presenting? (select all that apply) Unresponsive Slow pulse No pulse Breathing slowly Not breathing Blue lipsWhat did the patient overdose on? * Alcohol Heroin Benzos/Barbiturates Methadone Cocaine/Crack Suboxone Fentanyl Isotonitazene Etonitazene Carfentanil Any other opioid Don’t knowWas the Naloxone spray used provided to you by San Bernardino County staff? If so, please select the County Department that provided it to you.Department of Behavioral HealthDepartment of Public HealthDepartment of Public Health - ClinicsTransitional Assistance DepartmentHow many sprays did you use? 12345Did the spray stop the overdose? YesNoDon't KnowApproximately how long did the spray take to work?Did the person live? *YesNoDon't KnowDid you (or whoever used the spray) feel comfortable using it? After medical treatment was received, did the person who overdosed receive any type of substance use treatment or counseling? Submit