NJ Attorney General's Heroin & Opiates Task Force Naloxone Deployment Reporting Form Police Department: Case #: Date of Overdose: / / Time of Overdose: Location where overdose occurred: (Street address, City) Gender of the victim: Race/Ethnicity AM Female Black PM Address of victim:6WUHHWDGGUHVV&LW\ Male White : Hispanic Unknown Asian/Indian Age: American Indian Pacific Islander Signs of overdose present (check all that apply) Unresponsive Breathing Slowly Not Breathing Slow pulse No pulse Other (specify): Suspected overdose on what drugs Heroin Benzos/ Barbituates Alcohol Methadone Blue lips (check all that apply) Cocaine/ Crack Any other opioid Suboxone Don’t Know Other (specify): Evidence Heroin Stamp (Text/Color) Describe Image: Stamp (Text/Color) Describe Image: Opiate Pills Evidence Secured Pill Type: Doctor's Name: Paraphernalia Drugs Details of Naloxone Deployment Number of doses used: Did Naloxone work: If yes, how long did it take to work: Patient’s response to Naloxone <1 min Yes No 1-3 min Responsive and alert Post-Naloxone withdrawal symptoms (check all that apply) 3-5 min None Sternal Rub Recovery position Yelled Shook them EMS Naloxone Bystander Naloxone Other (specify): Care transfer to EMS Naloxone Information: No response to Naloxone Physically Combative Yes Rescue breathing Automatic Defibrillator Disposition: Don’t Know Irritable or Angry Did the person live: Other (specify): What else was done: >5 min Responsive but sedated Dope sick (e.g. nauseated, muscle aches, runny nose, and/or watery eyes) Vomiting Not Sure No Chest compressions Oxygen Other (specify): Lot #: Expiration date: / / Notes / Comments Officer’s Name Signature Date of Report Please email form to [email protected] and [email protected] or fax to NJROIC (609) 530-3650 and (732) 506-5088.