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Application for Naloxone Agreement with the Virginia Department of Health

Complete this form if your organization would like to request naloxone products through the Virginia Department of Health (VDH) for the first time, or if your organization's agreement with VDH has expired.
A fully executed agreement must be on file before VDH can provide naloxone or test strips.
For questions, contact: opioidreversal@vdh.virginia.gov.

federal agencies warning

  • Federal agencies should contact opioidreversal@vdh.virginia.gov before applying for a naloxone agreement.
  • VDH cannot ship to P.O. Boxes.
  • A red star (*) or a red upper left edge indicates that a field is required.
  • Be sure to review your information carefully before submitting.

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    Select all that apply.
    Select all that apply.
    If your organization had a previous naloxone agreement (MOA or MOU) with VDH, please enter the agreement number here. (Please do not provide more than one agreement number.)
    Your best guess is fine!
    In total, how many naloxone kits do you expect to order through the Expanded Access program?
    Your best guess is fine!
    To purchase naloxone through our Expanded Access program, you must first establish an Expanded Access agreement between your organization and the Virginia Department of Health (VDH). After you submit this application, we will send an Expanded Access agreement for your signature via Box Sign. VDH cannot ship any Naloxone until your Expanded Access naloxone agreement is fully executed.

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    If you are unsure which of these organization types applies to your organization, please select "Unsure" and someone from the VDH pharmacy team will reach out to you.
    This is the name that will be listed on the contract.
    This is the name that will be listed on the contract.
    This is the name that will be listed on the contract.
    What is the URL (web address) of your organization's website?
    This is the IRS nine-digit Employer Identification Number.

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    Select all localities that your organization serves.
    Is your organization tax-exempt under section 501(c)(3) of the Internal Revenue Code?

    Fire Info

    Name of Agency Chief Executive Officer (chief/sheriff/superintendent)
    Email of Agency Chief Executive Officer (chief/sheriff/superintendent)

    Have the employees who will carry and administer naloxone completed the REVIVE for First Responders Training Program?

    What is the total number of Firefighters and/or EMTs employed by your organization?

    Law Info

    Name of Agency Chief Executive Officer (chief/sheriff/superintendent)
    Email of Agency Chief Executive Officer (chief/sheriff/superintendent)

    Have the employees who will carry and administer naloxone completed the REVIVE for First Responders Training Program?

    What is the total number of sworn law enforcement officers, corrections officers, and probation/parole officers employed by your organization?

    Population info

    Does your program serve populations that are at a high-level of risk for opioid overdose?
    Please describe the population(s) your program serves or intends to serve, along with your experience working with this population(s). Include demographic information if known.
    General public distribution, such as at health fairs, community meetings, etc. is not allowed.
    Please provide additional context on how you are planning to use naloxone for this population (e.g., maintain as undesignated stock, dispense directly to individuals, REVIVE! Training events).

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    By submitting this form, you confirm that 1) the information you have provided is accurate, 2) you understand that VDH cannot ship to P.O. Boxes, and 3) your organization will not be able to order naloxone until your registration is approved and you have a fully executed naloxone agreement (MOU or MOA).