Monroe County Heroin Task Force

 

 

 

 

 

 

 

0D Response Date: OD Response Time: Arrival Time of EMS: I Fatal: Type Of Location: 

I 

Investigajng Agencw Responding Officer/Deputy (Name, Rank Contact 

1 ill .I I

Overdose Location: Drug TypeIs) . .. I

Known Drug History. (check all that apply) Naloxohe Administered? LEO Bureau
Photos Taken of Stamp? EMS 
Heroin Methadone CocamelCrack
. - DrugsIParaphernalia Present? OtherI:I
Alcohol CI Suboxone "Opioids

- If Yes, PleaSe elaborate.
?'5?er BenzosIBarbiturates Unknown Pills 
of Overdose A ..

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Other (specify) I 3

 

 

 

PackagianStamp Description (Color of package, etc.)

 

Prescription HUD

 

 

 

 

Doctor(specify I - 

 

 

Victim Information;

rVictinlNamezl: 3 if. Sex: Race

Victim Addressi(V)'sMedical Conditidns: I ?j I Contact#:I I: .
Consent to Search: CI Consent Given In: I 

 

 

 

 

Cell#.? Cell Recovered: CeIl Password:I -- I I: I Hand-Preference? 
DeceasedVehicle: NextofKin I I I Contact? I 3 I 

 

 

 

Supplier InfOrmation:

 

 

 

 

 

 

 

 

 

SUPPIICEI - I contacw? I ,3 I I
AliPurchasedLocationNotes:

 

 

 

 

Respondinngarcotics Detective.71 

Electronic Devices Seized: Password; Social Niedia information; Log-in Passyyord:

 

 

 

 

Additional Notes:

 

 

 

 

NYS SpeCific Information:-

 

Breathing- QBreathing Fast . .Breathing Slow . .Breathing Normally . .
Pulse: Fast Pulse Slow pulse . QNormal Pulse . No Pulse . Did Not Check Pulse

3

Aided Overdosed on What Drugs: (Check all that apply): .. . I
Heroin El BenzosIBarbiturates CocaineICrack BuprenorphinelSuboxone Pain- Pills El Unknown Pills

UHRNOWN ?1190than Alcohol Methadone El Don'-t Know El I - . 
Administration Of Naloxone #ofNaloxonevials used: . 1vial- . 2vials . 3vials . 4vials . >4vials

Didn't
How long did 1st dose of naloxone take to work! <1 minute. 1- 3 minutes. ?4 5 minutes. minutes. QDon' Know. 

Aidedwsresponse . Combative. QResponsive Responsive Responsive Unresponsive but No Response
&Alert butSedated Breathing 

 

 

 

8. Angry

If 2nd dose given, was mg .IN (instranasal) . 01M (intramuscular) IV (intravenous) .1
How long after ?lst dose was 2nd dose administered: a? minute ?1'3 minutes .?Hminu?es >5 minutes Don't Know

Aided's response: .Combative Responsive Responsive Responsive UnresponSive but No Response

8- Angry Alert but Sedated Breathing
Post naloxone (Check all that apply.) 

NOne 7 [1 Dope Si?k (e49. nauseated, muscle aches, runny nose andlor watery eyes) Respitory Distress

El Seizure I: Vomiting Other (specify): i ?2 
what Else was Done by the Responder: (Check all that apply)

El Yelled Shook Them El Sternal Rub Recovery Position Bag Valve Mask Mouth to Mask Mouth to
Mouth 

I: Defibrillator?fchecked, indicateStatus ofshock): Defibrillator noshock El ?Defibrillator- shockadministered

El Chest Compressions Oxygen 7 7 

Transporting Ambulance: I