Naloxone Distribution and Training Tracking Log

Tracks units of naloxone dispensed, training sessions delivered, and recipient demographics for overdose prevention programs. Supports funder reporting, health department submissions, and program quality review.

Event and Site Identification

• Distribution Date
  Date on which naloxone was dispensed or training was delivered.
• Distribution Site / Location Name
  Name of the facility, community site, or event where distribution occurred (e.g., 'Main Street Harm Reduction Center', 'Eastside Fire Station 4').
• Site Type
  Classify the setting where distribution took place.
• Staff / Volunteer Name and Role
  Full name and role of the person conducting the distribution and/or training (e.g., 'Jane Smith, RN – Program Coordinator'). Do not record SSNs or personal IDs here.
• Staff Naloxone Training Current (within 2 years)?
  Confirm the distributing staff member holds current naloxone administration and overdose response training. Reference: BOP Naloxone Procedures and Protocol (PS 1610.002).

Naloxone Kit Inventory and Dispensing Record

• Naloxone Formulation Dispensed
  Select the formulation(s) distributed at this event.
• Number of Naloxone Kits Dispensed (Total Units)
  Enter the total number of individual naloxone kits (not doses) dispensed at this event. Each kit typically contains 2 doses.
• Lot Number(s) of Naloxone Dispensed
  Record all lot numbers for naloxone units dispensed. Required for recall tracking and inventory reconciliation.
• Naloxone Expiration Date(s) Verified Before Dispensing
  Confirm all units dispensed have a valid expiration date at least 3 months from today. Expired product must not be distributed.
• Ancillary Supplies Included in Kit
  Confirm kits include required ancillary items per program protocol.
• Remaining Naloxone Inventory After This Event (Units On-Hand)
  Record the on-hand kit count after this distribution event for inventory reconciliation.
• Reorder Threshold Met? (Flag if inventory falls below program minimum)
  Indicate whether current on-hand inventory has dropped to or below the program-defined reorder threshold.

Training Delivery Record

• Was Overdose Response Training Delivered at This Event?
  Indicate whether structured training (overdose recognition, rescue breathing, naloxone administration, 911 activation) was provided.
• Training Format Used
  Select the primary training delivery method.
• Training Duration (Minutes)
  Approximate length of the training session delivered.
• Core Training Topics Covered
  Select all topics addressed during training.
• Number of Individuals Trained at This Event
  Total count of persons who received training (may differ from kits dispensed if bystanders or family members trained without receiving a kit).
• Hands-On Return Demonstration Completed by Participants?
  Confirm whether participants performed a return demonstration of naloxone administration (best practice per CDC evaluation guidance).
• Training Materials Language(s) Provided
  Select all languages in which written or verbal training materials were provided.

Recipient Demographics (Aggregate — Where Required by Funder)

• Instruction: Aggregate Data Only
  IMPORTANT: Enter aggregate (group-level) counts only. Do not enter individual names, dates of birth, Social Security numbers, or other PII. If your program uses individual-level tracking, record that data in your program's secure case management system, not here.
• Total Recipients Receiving a Kit at This Event
  Total number of unique individuals who received at least one naloxone kit.
• Recipient Type (Aggregate Count by Category)
  Select all recipient categories present at this event. Provide counts in the comments field.
• Number of First-Time Recipients (Never Previously Received Naloxone Kit)
  Count of individuals receiving a naloxone kit for the first time from your program. Used to measure program reach.
• Reported Overdose Reversals Since Last Distribution (Aggregate Count)
  Number of overdose reversals reported by returning recipients since the prior distribution event. Used for program outcome tracking per CDC evaluation guidance.
• Number of Used / Empty Kits Returned for Replacement
  Count of previously dispensed kits returned as used (naloxone administered) and exchanged for new kits.
• Referrals to Treatment or Other Services Provided
  Number of individuals referred to substance use treatment, harm reduction services, or other support resources at this event.

Storage, Cold Chain, and Handling Compliance

• Naloxone Storage Temperature at Distribution Site (°F)
  Record the ambient or refrigerated storage temperature where naloxone was held prior to distribution. Most formulations require storage between 59°F and 77°F (15°C–25°C); verify against manufacturer labeling.
• Naloxone Stored Away from Direct Sunlight and Moisture?
  Confirm storage location protects product from light and humidity degradation.
• Transport / Cooler Used for Mobile Distribution — Temperature Maintained?
  If naloxone was transported to a mobile or off-site distribution event, confirm temperature was maintained within acceptable range during transport. Select N/A if distribution occurred at a fixed site.
• Naloxone Secured Against Unauthorized Access When Not in Active Distribution?
  Confirm that naloxone inventory is locked or secured when not actively being dispensed, per program security protocol.

Documentation, Reporting, and Sign-Off

• Funder / Health Department Report Due Date (if applicable)
  Enter the next reporting deadline for which this event data will be submitted.
• All Kit Dispensing Data Entered into Program Database / Case Management System?
  Confirm that individual-level or aggregate data has been entered into your program's secure data system (e.g., REDCap, PDMP, or funder-specified platform) as required.
• Adverse Events or Incidents to Report?
  Indicate whether any adverse events (e.g., allergic reaction, kit malfunction, security incident) occurred during this distribution event that require incident reporting.
• Adverse Event / Incident Description (if applicable)
  If an adverse event or incident occurred, describe it here. Include date, nature of event, individuals involved (by role only, no PII), and immediate actions taken.
• Additional Notes / Observations
  Record any additional observations, barriers encountered, community feedback, or program improvement notes from this distribution event.
• Supervisor / Program Manager Review Completed?
  Confirm a supervisor or program manager has reviewed this log entry for accuracy and completeness before submission.
• Staff Signature
  Distributing staff member or volunteer signature attesting to the accuracy of this log entry.