Medication Training Program Skills Checklist

District Letterhead

Opioid OverdosePrevention Training Skills Checklist

Directions to trainer: Review the items on this form for successful knowledge and skills. Upon successful completion add the individuals name to the Opioid Overdose Prevention Staff Training Log Summary and sign their certificate of completion.

Trainer Name: Date:
Trainer Title :  RN NP PA MD/DO
School or Library Name:
School or Library Staff Member Name:
Knowledge Check for Administering Naloxone / Trainer
Initials / Date / Review Date/
Trainer Initials
Staff member provides a copy of Opioid Overdose Prevention Training post-test which indicates 100% accuracy
Identifies location of naloxone kit
Accurately identifies supplies in naloxone kit
Accurately follows product directions to administer naloxone
Identifies who naloxone use must be reported to
Describes documentation and reporting process as indicated in district or library policy/procedure
Skills Check for Administering Naloxone / Trainer
Initials
Assesses the victim by Shake, Shout, Sternal Rub
Calls/instructs someone to call 911 and activate school emergency response per policy
Obtains and correctly administers naloxone following steps below for either:
Multi-Step Naloxone with Mucosal Atomizer / Narcan ® (Adapt Pharma)
Removes the yellow caps from the plastic barrel and twist on the white atomizer. Remove the purple caps from glass vial of naloxone and twist it into the back of the plastic barrel. Insert the tip of the atomizer into one nostril and spray ½ of the dose. Spray the other ½ of the dose into the other nostril. Places victim in recovery position.After 2- 3 minutes if there is no or minimal response, repeat with second dose. / Peel back the packaging to remove the device. Hold the device with your thumb on the bottom of the plunger and 2 fingers on the nozzle. Do NOT press the plunger. Place and hold the tip of the nozzle in either nostril. Once the tip is in the nostril, press the plunger firmly to release the dose into the person’s nose. Places victim in recovery position. After 2- 3 minutes if there is no or minimal response, repeat with second device into other nostril.
If not breathing, provides 2 slow breaths, then 1 rescue breath every 5 seconds.

This training is valid for 2 years. Annual review is highly recommended.

This record should be maintained for 2 years unless superseded by updated training.

Trainer Signature: ______

Staff Member (Designee) Signature: ______

This document is located at under Heroin and Opioid Resources 3/18