Community Based Naloxone Program
Naloxone Kit Usage Survey Form
For any patients returning to your pharmacy to obtain a replacement naloxone kit, please provide the link or a copy of the Naloxone Kit Usage form to the individual and ask them to complete it and drop it off at the pharmacy. Please note that pharmacy staff will have to transcribe the paper form into the online survey. If this is not feasible, putting up signage or a poster with the link or QR code for the form may be preferable. The form is available in 2 formats:
For any patients returning to your pharmacy to obtain a replacement overdose kit, please provide a copy of the Overdose Kit Use Reporting form to the individual and ask them to complete it and drop it off at the pharmacy. The form is available in 2 formats:
- Online Survey – https://is.gd/naloxonekit
- PDF (Paper Version) – https://www.albertahealthservices.ca/assets/info/hrs/if-hrs-cbn-naloxone-kit-usage-form.pdf
Pharmacy Store Registration
Click here to REGISTER your pharmacy to participate in the program.
Whenever possible this form should be completed by the Pharmacy Manager. Please allow 2-3 business days for your registration to be completed. If you are not able to order kits after that time, please send an e-mail to email@example.com.
This program is only open to pharmacists, pharmacy technicians and pharmacy staff practicing in Alberta.
Used in emergency treatment of opioid overdose outside of hospital, naloxone is now an unscheduled drug in Alberta.
Pharmacies participating in the Community Based Naloxone program should ensure their staff are knowledgeable about the program by completing the following course.