Naloxone In Public Schools Reporting Form

Federal dollars supporting Naloxone training and distribution have been used to supply schools with Naloxone Nasal Spray. The Department of Health collects and reports all Naloxone administered as part of opioid-related grants where Naloxone has been purchased and distributed. Please complete the form below. Also, indicate if you would like to request replacement naloxone. The Department will provide replacement Naloxone as part of this grant until funds have been exhausted.

Questions can be directed to the Department of Health at Naloxone@state.sd.us or 605-773-4031.

School Representative Completing this Form
Patient/Student Information (Please do not include any patient/student identifiers in this reporting)

Age in Years

Signature

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First and Last Name