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Naloxone Program Application

The Washington Department of Health Overdose Education and Naloxone Distribution (OEND) program supports access to naloxone for people who are likely to experience or witness an opioid overdose. This program provides free naloxone to organizations and community groups for distribution to clients and community members. The OEND program also provides free overdose recognition and response trainings, and technical assistance to organizations that are interested in distributing naloxone.

The OEND program can provide free naloxone for overdose response for staff and volunteers at syringe service programs, street outreach programs, shelters and day centers, permanent supporting housing programs, and community behavioral health agencies (i.e., licensed Behavioral Health Agencies (BHAs) and substance use treatment programs).

Please note:

Tribes, tribal organizations, and Urban Indian Health Organizations can request naloxone using this form.
Please read if your organization is a Behavioral Health Agency (BHA) or an Opioid Treatment Program (OTP):
- BHAs or OTPs distributing low-barrier naloxone anonymously or without an eligible Senate Bill 5195 encounter can continue to apply for naloxone through the OEND Program.
- BHAs and OTPs should seek reimbursement for naloxone provided during eligible encounters. Eligible encounters under Senate Bill 5195 include:
  - Treatment for mental health or substance use disorder
  - Withdrawal management, secure withdrawal management, evaluation and treatment
  - Opioid treatment
- If you have questions regarding SB 5195 and the OEND program, please email naloxoneprogram@doh.wa.gov

After submitting the application:

We will review your application within 30 days. After review, eligible programs will be contacted to schedule an interview.
During the interview we will explain how the program operates, including data reporting requirements.
Programs will not receive naloxone until the application is approved and the interview is complete.

Application Date

M-D-Y

Has your program received naloxone from DOH in the last 12 months?

Yes

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Organization Name

* must provide value

Program Name (if applicable)

Website (optional)

Unique Identifier
Organization Name and Program Name

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Which of these best describes your program? (choose all that apply)

* must provide value

Licensed Behavioral Health Agency (BHA)

Diversion program (e.g., drug court, LEAD, Recovery Navigator)

Health clinic/FQHC

HIV service organization

Homeless service organization

Housing program

First responder naloxone leave behind program

Jail

Local Health Jurisdiction/Health Department

Mutual aid group

Naloxone vending machine

Re-entry program from jail or prison

Shelter and/or day center

Street outreach program

Substance use treatment program

Syringe service program

Tribe, tribal organization, or Urban Indian Organization

Youth services organization

Other

Other organization type:

The OEND program provides free naloxone to tribes, tribal organizations, and Urban Indian Organizations. Click here to request naloxone from that program.

Which substance use treatment services does your program provide?

Residential treatment facility

Medications for Opioid Use Disorder (MOUD)

Opioid Treatment Program (OTP)

Outpatient treatment

Withdrawal management and stabilization treatment facility

Why are you requesting naloxone?

* must provide value

To distribute to clients or community members

For the purpose of agency staff response to overdose

Your agency type is not eligible to recieve naloxone for the purpose of agency response to overdose. If you are seeking naloxone to keep at your agency and/or for staff members to carry, here are some additional resources:

Individuals in Washington State can get naloxone from pharmacies using the Statewide Standing Order to Dispense Naloxone. People may take this standing order to a pharmacy to get naloxone instead of going to a health care provider to get a prescription. The order doesn't cover any out of pocket costs. For more information about Washington State's naloxone standing order, visit Overdose Education and Naloxone Distribution.
Healthcare providers, pharmacies, and other eligible organizations can purchase naloxone from medical distributors including Cardinal Health and McKesson.
To purchase NARCAN® Nasal Spray directly from the manufacturer, visit NARCANDirect.com. Departments of health, EMS, law enforcement, schools/universities and community organizations may qualify to purchase NARCAN® Nasal Spray directly from Emergent Devices at the public interest price.
Remedy Alliance / For The People provides low-cost injectable naloxone to organizations that provide naloxone directly to people who use drugs and people at high risk of overdose.

eligible to receive kits for agency use? (1=yes, 0=no)

eligibility includes: ESD, BHA, Housing program, shelter/day center, street outreach, substance use treatment program, or SSP

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Eligible to receive kits for agency use

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High priority program? (1=yes, 0=no)

eligibility includes: SSP, Jail, First responder leave beind programs, and ESD's

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High or low priority program?

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Will you be distributing naloxone kits to clients during eligible encounters under Senate Bill 5195? These include:

Treatment for mental health or substance use disorder
Withdrawal management, secure withdrawal management, evaluation and treatment
Opioid treatment

Yes

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Primary contact name

* must provide value

Primary contact title

* must provide value

Primary contact email

* must provide value

Primary contact phone #

* must provide value

Backup contact name

* must provide value

Backup contact email

* must provide value

Backup contact phone #

* must provide value

What is the physical address where you would like naloxone delivered? (Note: we cannot deliver to post office boxes)

Recipient name

* must provide value

Street address

* must provide value

City

* must provide value

Zip code

* must provide value

Will this be your program's first time distributing naloxone kits?

* must provide value

Yes No

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Would you like injectable naloxone kits, nasal naloxone kits, or both?

* must provide value

Injectable only

Nasal only

Both injectable and nasal

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Please estimate how many nasal naloxone kits your program will need per month.

* must provide value

Please estimate how many injectable naloxone kits your program will need per month.

* must provide value

Please estimate where you will distribute naloxone by listing up to 5 counties where you anticipate distributing naloxone and the approximate % of naloxone that will go to each county.

	County Name	Percent of Distribution (1-100)
#1
#2
#3
#4
#5

Please enter county distribution percentages that add up to 100

Would you like training on overdose response, including how to use naloxone, and/or assistance with developing policies and procedures for a naloxone distribution program?

* must provide value

Yes

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