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Please complete this form if your organization would like to request naloxone and/or test strips through the Virginia Department of Health for the first time, or if your organization's agreement with VDH has expired. A fully executed agreement with your organization must be on file before VDH can provide naloxone or test strips.

Please note that VDH is only providing test strips to a limited number of eligible partners at this time.

For questions filling out this form, please contact opioidreversal@vdh.virginia.gov.

Thank you!

Organization Type

VDH has revised the previously named Naloxone Partner Program to focus on High-Impact Community Partner Organizations. 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.

Site Name

This is the name that will be listed on the contract.

CSB Site Name

CHR Site Name

There are only 10 authorized comprehensive harm reduction sites. If you are not one of these ten sites, please select a different organization type. If you are unsure whether your organization qualifies, please contact opioidreversal@vdh.virginia.gov.

Are you applying through VACP?

Are you applying through the Virginia Association of Chiefs of Police (VACP) First Responders Program?

First Responders Completed the REVIVE! training program

Has your organization completed the required REVIVE! Training for First Responders through VACP?

The basic REVIVE! Training is not sufficient for first responders and will not qualify you for no-cost naloxone. First responders are required to go through a separate industry-specific training. Contact stephanie@vachiefs.org for more information.

Program Serves High Risk Population

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).

Chief Executive Officer

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

Chief Executive Officer Email

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

First Responders Completed the REVIVE! training program

Have the employees who will carry and administer naloxone completed the REVIVE! for First Responders Training Program conducted by the VACP? (program requirement)

Number of Firefighters and/or EMTs

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

Number of Officers

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

Environment

style

Application for Naloxone Agreement with the Virginia Department of Health

federal agencies warning

Fire & Law Enforcement Info

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Environment

style

Application for Naloxone Agreement with the Virginia Department of Health

federal agencies warning

Application Information

Fire & Law Enforcement Info

Physical Address

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Shipping Address

Primary Contact

Secondary Contact

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