Naloxone Direct Program
STATE OF NEW JERSEY
Department of Human Services
Division of Mental Health and Addiction Services
Department of Human Services(DHS)
Division of Mental Health and Addiction Services(DMHAS)
Select Provider Type
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Community Peer Recovery Center (DMHAS Contracted)
County Correctional Facilities
County Prosecutors Office
DOL One Stop Center
Family Support Services
Harm Reduction Agency
Institutes of Higher Education (IHEs)
Local Health Department
Mental Health Providers
Mobile Outreach Vehicle
Non-OTP Treatment Program (DMHAS Contracted)
Opioid Overdose Recovery Program (OORP)
Support Team for Addiction Recovery (STAR)
Treatment Program (DMHAS Contracted)
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Unduplicated number of individuals served per year?
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Please Enter Agency
Please tell us your agency role and function.
Shipping Address (Must be able to receive deliveries – no P.O. Boxes.)
District of Columbia
Primary Contact Information (Primary Contact is for all communications regarding the program and must be authorized to sign on behalf of the agency.)
Approximately, what was your total naloxone utilization last year (e.g. Total number of kits used for overdose administrations, Leave Behind, general distribution)?
Are you receiving Naloxone from any additional sources other than DHS?
Additional source of Naloxone (enter comma separated for multiple sources)?
Total number of Naloxone kits received annually (i.e. other Sources)?
TERMS AND CONDITIONS
By registering, the Eligible Agency Participant certifies that it satisfies the State Program criteria, is eligible to participate, and its Authorized Representative has the authority to request naloxone and recovery materials from the State Program.
Eligible Agency Participant hereby certifies and agrees to the following terms and conditions:
Eligible Agency Participant, its authorized representatives, healthcare practitioners and direct care staff shall comply with all applicable federal and State law and implementing regulations, including but not limited to:
N.J.S.A. 2C:35-30 et seq.
N.J.S.A. 24:6J- 1 et seq.
N.J.S.A. 45:14-67.2 (as applicable)
Applicable Department of Health rules, regulations and policies, including but not limited to requirements to report administration
Applicable N.J. Office of the Attorney General rules, regulations and policies, including but not limited to requirements to report administration.
Eligible Agency Participant, its authorized representatives, healthcare practitioners and direct care staff have reviewed and completed training in opioid overdose prevention, response and treatment.
Eligible Agency Participant, its authorized representatives, healthcare practitioners and direct care staff shall keep and maintain such records as are necessary to fully disclose and report full compliance and use of naloxone requested/obtained through the State Program (e.g., number of kits administered, number of kits for Leave Behind, number of kits distributed).
Eligible Agency Participant, its authorized representatives, healthcare practitioners and direct care staff shall maintain all other naloxone supplies and financial resources dedicated to naloxone distribution, administration, training, information dissemination and record keeping. The State Program shall not supplant or displace existing supplies or resources available to Eligible Agency Participant.
The individual signing below is the authorized representative of Eligible Agency Participant, the contact and mailing information is true and accurate, and Eligible Agency Participant shall immediately notify State Program of any changes. State Program is authorized to contact the authorized representative regarding any matter arising from or relating to the State Program.
Eligible Agency Participant authorizes the State Program to use all data and information collected in connection with the State Program to conduct other public health and epidemiological surveillance activities, consistent with federal and State confidentiality laws.
Eligible Agency Participant, its authorized representatives, healthcare practitioners and direct care staff shall not transport, administer or dispense outside of New Jersey any naloxone requested/obtained through the State Program.
Eligible Agency Participant, its authorized representatives, healthcare practitioners and direct care staff shall not sell or trade for any goods or services any naloxone requested/obtained through the State Program.
Eligible Agency Participant, its authorized representatives, healthcare practitioners and direct care staff acknowledge and agree that the Department of Human Services, Department of Health, and the New Jersey Attorney General's Office reserve the right to restrict or revoke Eligible Agency Participant’s State Program participation and registration at any time, for any reason, in the State’s reasonable discretion.
Eligible Agency Participant has read and reviewed this Certification with its authorized representatives, healthcare practitioners and direct care staff. Eligible Agency Participant shall maintain a record of each individual’s acknowledgement and receipt of the terms and conditions contained herein.
Eligible Agency Participant has read, understands, and accepts all the terms and conditions for the State Program :