Report of the FDA-Approved Opioid Overdose Reversal Medication Administration

Report of the FDA-Approved Opioid Overdose Reversal Medication Administration
Name of County:
Date of Overdose Reversal Medication Administration:

MonthDayYear
Type of Person Emergency Medication Given to
Overdose Reversal Medication Administered By

Other
Overdose Reversal Medication Was
Title of Person Completing Form

Other
Should be Empty: