Emergency Naloxone Box Application

1. Name of the Organization: *This question is required.

2. Name and Position of person completing this request: *This question is required.

3. Email of person completing this request: *This question is required. This question requires a valid email address.

4. Phone number of person completing this request: *This question is required.

5. I have the authority to agree to the terms and conditions outlined in this application on behalf of my organization: *This question is required.

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Signature of

You must agree to all terms and conditions for your application to be reviewed.

6. I, on behalf of my organization, agree to the following terms and conditions:

Upon receipt of the Emergency Naloxone Box(es), my organization assumes all liability related to this Emergency Naloxone Box(es), including but not limited to, the improper usage of the Naloxone, the failure to stock or re-stock this Emergency Naloxone Box(es) with Naloxone, and any injury, harm, or damage that may occur to property or individuals using this Emergency Naloxone Box(es). *This question is required.

7. I, on behalf of my organization, agree to the following terms and conditions:

Upon receipt of the Emergency Naloxone Box(es), my organization assumes all responsibility for the maintenance of this Emergency Naloxone Box(es), including the location of the box and the climate control requirements. *This question is required.

8. I, on behalf of my organization, agree to the following terms and conditions:

Upon receipt of the Emergency Naloxone Box(es), my organization assumes all responsibility for stocking, restocking, and replacing used or expired naloxone doses in this Emergency Naloxone Box(es). *This question is required.

9. I, on behalf of my organization, agree to the following terms and conditions:

Upon receipt of the Emergency Naloxone Box(es), my organization assumes all responsibility for acquiring Naloxone for purposes of stocking this Emergency Naloxone Box(es). *This question is required.

11. How many Emergency Naloxone Boxes are being requested: *This question is required.

11. Have you experienced an opioid overdose at the location in which you plan to add an Emergency Naloxone Box? *This question is required.

12. Upload a 2-page or less description to include:

How the organization is poised to support overdose prevention efforts
Where the requested Emergency Naloxone Box will be physically located.
- This description should be specific and include at a minimum:
  - Physical address(es)
  - Description of how accessible the emergency box will be at the physical address
  - Confirmation that the location the box will be placed is climate control to ensure the naloxone stays within the required temperature range of 36 - 77 degrees Fahrenheit

*This question is required.

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13. Upload the policy and procedures related to the maintenance of the requested Emergency Naloxone Box, including how often they will be checked and have naloxone replaced if needed. *This question is required.

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14. Upload the organization's training plan for staff including how to recognize and respond to an overdose and how to replace used doses of naloxone; this must be 2 pages or less. *This question is required.

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15. Does the organization currently receive naloxone or Narcan doses directly from the Department of Health? *This question is required.

16. Provide the name for the individual responsible for ordering Narcan from the Department of Health: *This question is required.

16. Provide the email for the individual responsible for ordering Narcan from the Department of Health: *This question is required. This question requires a valid email address.