Section 12. Minimum Requirements For Enrollment And Record Of Use Forms

A. The enrollment form shall include at a minimum: (1) name of the overdose prevention and education program; (2) department designated code of the trained targeted responder; and (3) the quantity of the opioid antagonist distributed. B. The record of use form shall contain at a minimum: (1) the name of the overdose prevention and education program recording the report; (2) the department designated code of the reporting trained targeted responder; (3) the quantity of the opioid antagonist administered, lost, or expired; (4) the date or approximate date of the overdose incident, if there is one being reported; (5) the disposition of the person who was administered the opioid antagonist; and (6) the quantity of the opioid antagonist distributed.