Part 3, Chapter 35: Manual Exhibit 3-35-A

Manual Exhibit 3-35-A

Date of Issuance _____________

1. The Indian Health Service (IHS) facility, _______________________________, under the direction of, __________________________, the local Medical Control Provider (MCP) will dispense Opioid Overdose Kits containing naloxone to the ______________________________.
2. The pharmacist (or designee), __________________________, has confirmed that the First Responder __________________________, has completed the MCP approved naloxone and opioid overdose training.
3. The Opioid Overdose Kit contains at least one of the following: (select all that apply
   • Intranasal Naloxone (Narcan? Nasal Spray)
   • Auto-Injector Naloxone (Evzio?) for intramuscular or subcutaneous administration
   • Naloxone injection syringe and mucosal atomizer device for intranasal administration
4. The Opioid Overdose Kit may also contain the following (select all that apply):
   • Naloxone administration instructions
   • Gloves
   • Face shield to provide rescue breathing
   • Other __________________________
5. Reason for Replacement Kit (circle one):
   • Used for an emergency
   • Expired
   • Damaged (describe) _________________________________________
   • Lost (describe) _____________________________________________
6. Lot Number:_____________________ Expiration Date:_____________________