The Works Naloxone Assessment Form – Initial and Refill

□Initial dispensing
□opioid user / □Friend or family of opioid user
Refill: □usedforoverdose □lost □stolen □expired □confiscated □broken □left at home
Location: □The Works □Works Van □Outreach □SIS
Code:______/ ______/______/______
Code = LAST two letters of surname, LAST two letters of first name, numerical day of birth / birth month / full birth year )
Gender:□F□M□T □Other: / □entered inNeo
Dispensed:(#)____ xNaloxone4 mg/0.1mLspraylot#______
Dispensed:(#)____ xNaloxone4 mg/0.1mLspraylot#______/ Expiry(mm/yyyy): ______
Expiry(mm/yyyy): ______
Staff Signature: ______ / Date(dd/mm/yyyy):______
Overdose Prevention / - demonstrates clear knowledge of overdose risk factors and overdose
prevention
Signs of Opioid Overdose /
  • - demonstrates knowledge of the signs of opioid overdose
  • - understands the difference between nodding and overdose

Calling 911 / - understands the importance of calling 911
  • - knows how to interface with EMS dispatch and paramedics

Naloxone
Administration /
  • - knows how to administer naloxone (route, location)
  • - understands the indications for administering subsequent naloxone dose(s)

Stimulation, CPR & Myths /
  • - knows how to provide stimulation to unresponsive person
  • - rescue breathing and/or chest compressions as trained
  • - understands overdose response myths

Aftercare /
  • - knows naloxone's duration of action
  • - understandsimportance of discouraging the person from using more opioids
  • opioids and to watch for the return of overdose symptoms
  • - knows how and when to put the person into the recovery position
  • -understands the need to stay with someonefor 2hrs if 911 was not called

Naloxone Care, Refills, Program Evaluation /
  • - knows how to store naloxone (temperature)
  • - knows to keep naloxone handy and monitor expiry date
  • - knows to contact The Works for refill, reporting, overdose debrief
- awareof POINTdatacollectionandusegovernedbyH.P.P.A.

Personalinformationonthis form iscollectedunderthe authorityof the HealthProtectionandPromotionAct[H.P.P.A] for the purpose of providingNaloxone andaggregatingdata about the use ofour servicesatacommunitylevel. Ifyouhave anyquestionsaboutthe collectionor use ofyour personal information,please contactShaun Hopkins, Manager, The Works,277 Victoria Streetor 416-392-0520.

Revised October, 2017