1. A. The enrollment form shall include at a minimum:

   1. (1) name of the overdose prevention and education program;
   2. (2) department designated code of the trained targeted responder; and
   3. (3) the quantity of the opioid antagonist distributed.

2. B. The record of use form shall contain at a minimum:

   1. (1) the name of the overdose prevention and education program recording the report;
   2. (2) the department designated code of the reporting trained targeted responder;
   3. (3) the quantity of the opioid antagonist administered, lost, or expired;
   4. (4) the date or approximate date of the overdose incident, if there is one being reported;
   5. (5) the disposition of the person who was administered the opioid antagonist; and
   6. (6) the quantity of the opioid antagonist distributed.

[7.32.7.12 NMAC-N, 7/15/2016]