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Mont Co First Responder Naloxone Program - Enrollment Process

  1. Montgomery County First Responder Naloxone Program Enrollment Process
  2. Thank you for your interest in Montgomery County’s First Responder Naloxone Program. This packet will provide you with all the information needed to complete the enrollment process.
  3. • It is important to work with EMS agencies within your jurisdiction to ensure all responders are aware of your agency’s participation in the naloxone program. An MOU must be signed between the doctor with your agency and an EMS agency Medical Director or with the Montgomery County Regional Medical Director.
  4. • Naloxone can only be provided to and administered by responders who have received the mandatory PA Department of Health and Montgomery County Department of Public Safety training. You must verify that all potential responders have received the required training and instructional materials, which cover recognition of opioid related overdoses and the administration of naloxone (Please see the First Responder Training Checklist for specific requirements.)
  5. • You must maintain records regarding the storage, distribution, and deployment of naloxone.
  6. • All responders must comply with reporting requirements regarding the use of naloxone. Specifically, all responders must submit the Naloxone Administration Form within 24 hours of usage.
  7. • Naloxone must be stored at a consistent storage temperature and the medication should not be exposed to temperature extremes.
  8. • It is important to monitor the expiration dates of the naloxone supply and notify the Department of Public Safety within 30 days of expiry for acquisition of replacement stock (if available).
  9. • Resupply of naloxone can be obtained by contacting the Department of Public Safety, if supplies are available and your agency is eligible and has completed all required documents.
  10. Please submit the following documents to begin the enrollment process:
  11. *REQUIRED FOR Law Enforcement Agencies & Fire Departments/Companies
  12. Once all program requirements have been met, a supply of naloxone will be issued to your agency. Should you have any questions regarding this process, or if you need further assistance, please email
  13. My Organization will be using the kits for
    (select all that apply)
  14. Application
  15. Note: The number of kits requested may not equal the number of employees. Supplies are closely monitored. Request kits for use by all employees in common geographic areas, e.g. 1 per floor/building.
  16. Approved Training Resources and Affirmation
  17. APPROVED TRAINING RESOURCES - REQUIRED FOR Law Enforcement Agencies & Fire Departments/Companies
  18. General Trainings (check one):
  19. Administer NARCAN® Nasal Spray Training - (must check both):
  20. AFFIRMATION - REQUIRED FOR Law Enforcement Agencies & Fire Departments/Companies
    I hereby certify that I have completed the above-approved administration of Naloxone training programs. All those to whom I intend to provide a Naloxone kit for use in an overdose emergency have received training by the approved courses. I understand that there is additional information located at that is specific to the Naloxone kits provided to me.
  21. e.g. /s/ John Smith
  22. Leave This Blank:

  23. This field is not part of the form submission.