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 City What signs was the patient presenting? (select all that apply) UnresponsiveSlow pulseNo pulseBreathing slowlyNot breathingBlue lips What did the patient overdose on? * AlcoholHeroinBenzos/BarbituratesMethadoneCocaine/CrackSuboxoneFentanylIsotonitazeneEtonitazeneCarfentanilAny other opioidDon’t know Was the Naloxone spray used provided to you by San Bernardino County staff? If so, please select the County Department that provided it to you. How many sprays did you use? Did the spray stop the overdose? Approximately how long did the spray take to work? Did the person live? * Did 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?