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

Manual Exhibit 3-35-A

Indian Health Service
First Responder Naloxone Program
Acquisition Form

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:_____________________
Pharmacist (or designee)
First Responder