New York State Public Safety Naloxone Administration Reporting
(Last Updated: 6/17/2024)

Registered and non-registered public safety programs including law enforcement and non-EMS fire departments should report naloxone usage data on this page, www.nyoverdose.org/publicsafety. Log-in not required. Emailed reports are no longer needed, please use this updated fillable PDF for internal needs.

EMS agencies, including EMS fire departments, registered with the Bureau of Emergency Medical Services and Trauma Systems (BEMSATS) that submit prehospital care reports to the State, will not submit a separate report through the New York State Public Safety Naloxone Administration Reporting website. Questions on EMS reporting, email emsdata@health.ny.gov.

Questions on law enforcement or non-EMS fire naloxone administration reporting, email publicsafetynaloxone@health.ny.gov.



Part 1. Responder Information

1.
Responding agency type:
     
Law Enforcement
     
Fire
     
Other (specify)

2.
Name of the responding agency:
 

3.
Name of responder who administered naloxone:
     

4.
Name of person filling out this form, if different than above:
     

5.
Please select the date the responder arrived at the scene of the suspected overdose:
     

6.
Please select the time of 911 call for the suspected overdose:
     
Enter Time
:
     
No 911 call was made
     
Unknown

7.
Please select the time the responder arrived at scene of the suspected overdose:
:

8.
Please select the time of EMS arrival at the scene of the suspected overdose:
     
Enter Time
:
     
EMS did not arrive
     
Unknown

9.
Agency Case Number:
     

Part 2. Information about Suspected Overdose

10.
County in which the suspected overdose occurred:

11.
The 5 digit zip code in which the suspected overdose occurred:
     

12.
Perceived gender of the aided:
     
Female
     
Male
     
X
     
Unknown

13.
What is the age of the aided?
       

14.
Perceived race of the aided:
      Asian
      Black
      Native American
      White
      Unknown
      Other race (specify):

15.
Perceived ethnicity of the aided:
     
Hispanic
     
Not Hispanic
     
Unknown

Part 3: Aided Status and Response Actions

16.
Prior to administering naloxone, what was the state of the aided's breathing?
     
Breathing fast
     
Breathing slow
     
Breathing normally
     
Not breathing

17.
Prior to administering naloxone, what was the aided's level of responsiveness?
     
Unresponsive
     
Responsive and sedated
     
Alert and responsive

18.
Which substance(s) is the aided likely to have used?
      Heroin
      Fentanyl
      Xylazine
      Benzodiazepines
      Methamphetamine
      Psychedelics (such as Molly, ecstasy, PCP)
      Cocaine/Crack
      Buprenorphine (such as Suboxone, Zubsolv, Subutex, Sublocade)
      Methadone
      Alcohol
      Cannabis (marijuana)
      Synthetic Cannabinoids (K2/Spice/Spike)
      Opioid Pain Pills (such as Percocet, oxycodone, oxycontin, hydrocodone, morphine)
      Non-Opioid Prescription Pills (such as sleeping pills, antidepressants, antipsychotics)
      Unknown Pills
      Unknown Injection
      Don't know
      Other (specify)

19.
What types of naloxone did the responder use?
 
      Intranasal 4mg (Narcan): White color label with red lettering
      Intranasal 8mg (Kloxxado): Orange color label with white lettering
      Intranasal 2mg: Generic requiring assembly
      IV (Intravenous)
      IM (Intramuscular)
      Other (specify)

20.
Was naloxone administered by someone else, outside of your agency, at the scene?
      Law Enforcement
      EMS
      Fire
      Bystander
      Unknown
      No
      Other (specify)

21.
To the best of the responder’s knowledge, how many total doses of naloxone were administered?
 
       

22.
How many doses of naloxone were administered by your agency only?
 
       

23.
What was the rate of the aided’s breathing after approximately five minutes from the last dose of naloxone administered?
     
Breathing fast
     
Breathing slow
     
Breathing normally
     
Not breathing

24.
Based on the responder’s last contact with the aided, how was the aided’s status after naloxone administration?
     
Responsive and alert
     
Responsive and sedated
     
Responsive and angry/combative
     
Unresponsive
     
Deceased
     
Other (specify)

25.
What other actions were taken by the responder?
 
      Yelled
      Shook Them
      Sternal Rub
      Recovery Position
      Bag Valve Mask
      Mouth to Mask
      Mouth to Mouth
      Defibrillator
      CPR/ chest compressions
      Oxygen
      Transferred care to EMS
      Other (specify)
      None

26.
Did the aided show any of the following symptoms after the administration of naloxone?
      None
      Vomiting
      Diarrhea
      Other withdrawal symptoms including sweating, shivering, nausea, runny nose, watery eyes, and/or muscle aches
      Lethargy
      Disorientation
      Respiratory distress
      Seizures
      Unknown
      Other (specify)

27.
Did the aided survive?
     
Yes
     
No
     
Don't know

28.
Was the aided transported to the hospital?
     
Yes
     
No- Aided was deceased
     
No- Transport was refused
     
Unknown
     
Other (specify)

29.
Hospital destination
 

31.
Was naloxone left behind for the aided or anyone else at the scene of the suspected overdose?
      Yes, for the aided
      Yes, for a bystander
      No, naloxone was not left behind
      Unknown
      Other (specify)

32.
Please provide additional comments about the naloxone administration, the aided's status prior to or after administration, hospital transport or other relevant information.
     

33.
If you would like to receive a copy of this form, please provide an email address:
      1.

      2.

      3.

Thank you for taking the time to complete this form. All data submitted are confidential.