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2. Montgomery County First Responder Naloxone Program Enrollment Process
4. 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.
6. • 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.
8. • 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.)
10. • You must maintain records regarding the storage, distribution, and deployment of naloxone.
12. • 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.
14. • Naloxone must be stored at a consistent storage temperature and the medication should not be exposed to temperature extremes.
16. • 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).
18. • 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.
20. Please submit the following documents to begin the enrollment process:

    1. Naloxone Program Application (below)
    2. *Training Affirmation and/or Training Certificates (below)
    3. *A copy of the MOU between your organization and either a physician affiliated with your group requesting naloxone, your local EMS agency Medical Director, OR the Mont. Co. Regional Medical Director
    4. *A copy of your organization’s EMS policy and procedure on response and treatment
22. *REQUIRED FOR Law Enforcement Agencies & Fire Departments/Companies
24. MOU
25. Organization's EMS Policy
27. 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 GetNarcanCCE@montgomerycountypa.gov.
29. I am requesting Naloxone for
    -- Select One --First Responder Organizational Response to Emergency Calls for OverdoseTreatment and Handoff Organization-SUD-OUD

    (select one)
31. My Organization will be using the kits for

    1. For Organization Response To Emergency Overdoses
    2. Distributing to Individuals after treatment (warm handoff/release from facility take home/leave behind kits

    (select all that apply)
33. Application
35. Organization Name*
37. Street Address*
39. City*
40. State*
41. Zip*
43. Municipality*
    -- Select One --Abington TownshipAmbler BoroughBridgeport BoroughBryn Athyn BoroughCheltenham TownshipCollegeville BoroughConshohocken BoroughDouglass TownshipEast Greenville BoroughEast Norriton TownshipFranconia TownshipGreen Lane BoroughHatboro BoroughHatfield BoroughHatfield TownshipHorsham TownshipJenkintown BoroughLansdale BoroughLimerick TownshipLower Frederick TownshipLower Gwynedd TownshipLower Merion TownshipLower Moreland TownshipLower Pottsgrove TownshipLower Providence TownshipLower Salford TownshipMarlborough TownshipMontgomery TownshipNarberth BoroughNew Hanover TownshipNorristown BoroughNorth Wales BoroughPennsburg BoroughPerkiomen TownshipPlymouth TownshipPottstown BoroughRed Hill BoroughRockledge BoroughRoyersford BoroughSalford TownshipSchwenksville BoroughSkippack TownshipSouderton BoroughSpringfield TownshipTelford BoroughTowamencin TownshipTrappe BoroughUpper Dublin TownshipUpper Frederick TownshipUpper Gwynedd TownshipUpper Hanover TownshipUpper Merion TownshipUpper Moreland TownshipUpper Pottsgrove TownshipUpper Providence TownshipUpper Salford TownshipWest Conshohocken BoroughWest Norriton TownshipWest Pottsgrove TownshipWhitemarsh TownshipWhitpain TownshipWorcester Township
45. Organization Contact: First Name*
46. Organization Contact: Last Name*
48. Phone Number*
49. Email*
51. Type of First Responder*
    -- Select One --Adult Probation or Parole OfficerAfter School Program PersonnelConstableCounty Correctional FacilitiesDomestic Violence Shelter PersonnelDrug Treatment ProvidersEMSFirefighterHomeless Shelter PersonnelJuvenile Probation OfficerLaw EnforcementLibrary PersonnelOther Legally Organized Community GroupPublic Defenders' OfficersPublic Transportation DriverSchool Nurse
53. Local EMS*
    -- Select One --Bryn Athyn Fire Company Ambulance Cheltenham Township EMS Community Ambulance Association, AmblerFriendship HLH Ambulance, Inc. Gilbertsville Area Community Ambulance Goodwill Stream Fire Engine Co.#1 Ambulance Harleysville Area Emergency Medical Services Horsham Fire Company Ambulance Lower Providence Comm Ctr AmbulanceNarberth Ambulance Plymouth Community Ambulance Association Second Alarmer’s Rescue Squad Skippack Emergency Medical Services Souderton Community Ambulance AssociationTrappe Fire Company Ambulance Upper Merion Fire/EMS Upper Perkiomen Valley Ambulance Volunteer Medical Service Corps of LansdaleWhitemarsh Ambulance
55. Number of Employees*
56. Number of Kits Requested*
    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.
58. Approved Training Resources and Affirmation
60. APPROVED TRAINING RESOURCES - REQUIRED FOR Law Enforcement Agencies & Fire Departments/Companies
62. General Trainings (check one):

    1. PA Virtual Training Network – https://www.pavtn.net
    2. Get Naloxone Now - http://www.getnaloxonenow.org/online
64. Administer NARCAN® Nasal Spray Training - www.narcan.com (must check both):

    1. See How to Use Video
    2. Law Enforcement Roll Call Video
66. 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 https://www.narcan.com that is specific to the Naloxone kits provided to me.
68. Reponder's Printed Name
69. Agency
71. Responder's Signature
    e.g. /s/ John Smith
72. Date
    Date
Leave This Blank:


74. 1. Receive an email copy of this form.
75. Email address

    This field is not part of the form submission.

76. Submit Submit and Print

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