Templates › Inspections › SEO page

Run: Naloxone Distribution and Training Tracking Log

Track every naloxone distribution event, training session, and inventory handoff in one log. Use it to document who was trained, what was dispensed, and what...

Fill this out, get a PDF emailed to you. No account required. Want to run it with your team and track results? Sign up free →

Event and Site Identification

Distribution Date critical (required)

Date on which naloxone was dispensed or training was delivered.

Distribution Site / Location Name critical (required)

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 critical (required)

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)? critical (required)

Confirm the distributing staff member holds current naloxone administration and overdose response training. Reference: BOP Naloxone Procedures and Protocol (PS 1610.002).

Yes No N/A

Naloxone Kit Inventory and Dispensing Record

Naloxone Formulation Dispensed critical (required)

Select the formulation(s) distributed at this event.

Number of Naloxone Kits Dispensed (Total Units) critical (required)

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 critical (required)

Confirm all units dispensed have a valid expiration date at least 3 months from today. Expired product must not be distributed.

Yes No N/A

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.

Yes No N/A

Training Delivery Record

Was Overdose Response Training Delivered at This Event? critical (required)

Indicate whether structured training (overdose recognition, rescue breathing, naloxone administration, 911 activation) was provided.

Yes No N/A

Training Format Used

Select the primary training delivery method.

Training Duration (Minutes)

Approximate length of the training session delivered.

Core Training Topics Covered critical (required)

Select all topics addressed during training.

Number of Individuals Trained at This Event critical (required)

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).

Yes No N/A

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 critical (required)

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.

Note (optional)

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) critical (required)

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? critical (required)

Confirm storage location protects product from light and humidity degradation.

Yes No N/A

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? critical (required)

Confirm that naloxone inventory is locked or secured when not actively being dispensed, per program security protocol.

Yes No N/A

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? critical (required)

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.

Yes No N/A

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.

Yes No N/A

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? critical (required)

Confirm a supervisor or program manager has reviewed this log entry for accuracy and completeness before submission.

Yes No N/A

Staff Signature critical (required)

Distributing staff member or volunteer signature attesting to the accuracy of this log entry.

Get your results

Enter your email — we'll send you a PDF of your filled-out template, plus the occasional MangoScoop newsletter (templates, workflow tips, product updates). Unsubscribe anytime — link is in every email.

Email (required)

Your name (optional)

Generated with MangoApps Templates — browse 250+ free