Naloxone Usage Form Naloxone Usage Reporting Please complete the information below to report the usage of naloxone kits that were provide through Scott County EMS. Please enable JavaScript in your browser to complete this form.Name *FirstLastEmailNumber of Doses Used: *One (1)Two (2)Did the patient improve? *YesNoDid the patient become combative after administration? *YesNoGender of Patient: *MaleFemaleAge of Patient *Age of PatientUnder 1515 - 2425 - 3435 - 4445 - 5455 - 6465 +Outcome *Outcome of PatientTransported by AmbulanceTransported by Family/FriendTransported by Law EnforcementDid not call 911OtherDo you wish to be contact about a replacement naloxone kit? *YesNoPhoneSubmit