You are viewing an old version of this page. View the current version.

Compare with Current View Page History

Version 1 Current »


Ontario Naloxone Program
Ministry of Health

 

 

 

 

 

 

 

 

 

 

Quarterly Reporting Form

 

 

 

 

 

 

 

 

 

 

ONP Site Name:

 

 

 

 

 

 

 

 

Quarter:

 

 

Contact Name:

 

 

 

 

Contact Email:

 

 

 

Contact Tel:

 

 

Select Organization Type

 

 

 

 

 

 

 

 

 

 

Core ONP Site/Naloxone Distribution Lead

 

Emergency Department

 

 

Fire Service

 

 

 

 

AIDS Service Organization

 

Expanded Access Organization

 

 

Police Service

 

 

 

 

Aboriginal Health Access Centre

 

Outreach Program

 

 

St. John Ambulance

 

 

 

 

Community Health Centre

 

Shelter

 

 

 

 

 

 

 

 

Consumption & Treatment Service

 

Withdrawal Management Program

 

 

 

 

 

 

 

 


Key outcomes for the quarter

Output

Number

Injectable Naloxone Distributed

 

Number of injectable naloxone kits distributed to individuals

 

Number of single refill injectable ampoules distributed to individuals
(1 box = 10 refill ampoules).

 

Nasal Spray Naloxone Distributed

 

Number of nasal spray naloxone kits distributed to individuals

 

Number of single refill nasal sprays distributed to individuals
(1 box = 2 refill sprays)

 

Individuals Trained

 


Number of individuals trained to administer naloxone

 


Please provide information about drug trends in your community and/or a need for naloxone in your community that is not being filled.






 

Due Dates

 

 

 

 

Q1 (Apr – Jun)

Q2 (Jul – Sep)

Q3 (Oct – Dec)

Q4 (Jan – Mar)

Aug 1

Nov 1

Feb 1

May 1

 
  • No labels