EOHHS-DPH

Please note any questions below with (Required) are mandatory.

Section 1: General Information

1. Contact information:

a. Agency Name:(Required)

b-d. Address(Required)

Street Address Town/City State Zip Code

e. CNP Coordinator Name:(Required)

f. CNP Coordinator Job Title:(Required)

g. CNP Coordinator E-Mail Address:(Required)

h. CNP Coordinator Phone Number:(Required)

i. Secondary Contact Name:(Required)

j. Secondary Contact Job Title:(Required)

k. Secondary Contact E-Mail Address:(Required)

l. Secondary Contact Phone Number:(Required)

2. Would your agency like to be considered for fully subsidized naloxone, in exchange for additional, monthly data reporting to DPH? (select one)(Required)

Yes

No

By selecting “no”, your agency is indicating that they want to purchase naloxone at the state-negotiated public interest pricing and not get it for free. Agencies that purchase the naloxone from DPH are required to provide data reports annually.

3. Please select the program type(s) that best describes your agency: (select all that apply)(Required)

BSAS-licensed, -approved, or -contracted facility

Hospital or hospital-affiliated clinic/department/program

Emergency Medical Services

Human services providers that work with people at risk for overdose and/or their social networks

Co-Response, jail diversion, crisis intervention, and/or or post-overdose support and response

Substance Use Disorder family advocacy and/or support groups

Municipality or health department

Other

If other, please enter:(Required)

4.  Does your agency already have an active, valid Massachusetts Controlled Substances Registration (MCSR) for naloxone (or Schedule VI medications)? (select one)(Required)

Yes

No

An MCSR is required at all addresses where the state ships prescription naloxone. If your agency doesn’t have an active, valid MCSR for naloxone (or Schedule VI medications) and will be ordering prescription naloxone there are two options:

You can apply directly for an MCSR application with your own Medical Director (health care practitioner with a license) on the Health Professions Licensing System (no fee required).
You can request an MCSR through the CNP using the state Medical Director, Dr. Alex Walley. If so, you MUST include your agency’s tax ID in the attachments of this application. The MCSR will be registered for the address included on the application unless otherwise specified. Out of state addresses and P.O. boxes will not be accepted.

**Note: An MCSR is not required for CNP affiliate programs ordering over-the-counter (OTC) naloxone (this includes Narcan®).

5. Is the address listed above (in question 1) the only location where CNP-obtained naloxone will be delivered? (select one)(Required)

Yes

No

IF “No” SELECTED: 5a. please list the addresses of each additional location where naloxone accessed through the CNP will be delivered:(Required)

Please submit an MCSR certificate or application for each location where naloxone will be delivered with your application.

6. Will the naloxone obtained through the CNP be available to individuals who do not access your agency’s other services? (select one)(Required)

Yes, even if they are only interested in obtaining naloxone

No, but anyone (or anyone who meets certain criteria) can access my agency’s other services, and would then be able to obtain naloxone

No – my agency’s other services are limited to closed referrals

Varies by location

7. Does your agency have a pharmacy that is (or could be) utilized to dispense naloxone to patients or clients? (select one)(Required)

Yes

No

7a. If “yes” selected: please state the reason why this pharmacy does not meet your current needs, and why you are applying for the CNP:(Required)

Section 2: Program Activities

1. Please briefly describe your program’s experience with providing overdose prevention and harm reduction services:(Required)

2. How do you plan to distribute the naloxone? Include who you plan to reach and in what settings your program plans to provide overdose prevention education and naloxone distribution in (mobile outreach, home visits, shelter sites, jails, medical sites, etc.):(Required)

3. Please describe how your program will coordinate and communicate with existing overdose prevention and harm reduction programs servicing your area. If you do not have existing relationships with an active harm reduction program servicing your area, please explain (programs without existing relationships with harm reduction programs are still eligible for CNP):(Required)

Section 3: Attachments

1. Please attach a single, PDF or Word Document that contains the following 2-3 documents: MCSR documentation, a proposed outline, and a signed letter if an EMS program (more information below). PLEASE ENSURE THAT YOUR ATTACHMENT INCLUDES A RESPONSE TO BOTH “A” AND “B” BELOW (Part c is only required for emergency medical services). Applications without this information included will not be accepted.

File(Required)

Drop files here or

Accepted file types: pdf, doc, docx, Max. file size: 50 MB.

a) MCSR documentation

Please refer to the MCSR application instructions in Section 1, Question 5 of the application. Include only one of the following:

If your agency has an active, valid MCSR for naloxone (or Schedule VI medications): a copy of an MCSR certificate for each delivery location
If your agency doesn’t have an active, valid MCSR for naloxone (or Schedule VI medications) please state whether or not you are:
1. Applying directly for an MCSR application with your own Medical Director (health care practitioner with a license) on the Health Professions Licensing System (no fee required).
2. Requesting an MCSR through the CNP using the state Medical Director, Dr. Alex Walley. If so, you MUST include your agency’s tax ID. The MCSR will be registered for the address included on the application unless otherwise specified. Out of state addresses and P.O. boxes will not be accepted.

b) A proposed outline for your agency’s CNP-related processes

The outline should include the following components:

Roles of key staff members 
Protocols detailing how:
- Recipients will be identified, trained, and provided with naloxone 
- Naloxone inventory will be stored, tracked, and maintained 
- Data collection will be performed for the following metrics:
  - Number of naloxone doses distributed 
  - Number of persons trained 
  - Number of overdose reversals reported back to program

c) If you selected “Emergency Medical Services” in Section 1, Question 4 of the application: a signed letter from your agency’s Affiliate Hospital Medical Director (AHMD)

This letter must state that your agency has met the conditions for participation in leave-behind naloxone, outlined in the Massachusetts Pre-Hospital Statewide Treatment Protocols 2021.2, Section 6.12 (PDF) | (DOC).

1. All applicants must attest to the following, in order to be considered as an affiliate program for CNP: (must select all)

MDPH Core Competencies for OEND Programs (PDF) | (DOC)

IF “Hospital or hospital-affiliated clinic/department” or “Emergency Medical Services” WAS SELECTED FOR SECTION 1, QUESTION 3:

2. All applicants indicating that their agency is a hospital, hospital affiliated clinic/department, or emergency medical service must attest to the following, in order to be considered as an affiliate program for CNPP: (must select all)

IF “Yes” WAS SELECTED FOR SECTION 1, QUESTION 2:

3. All applicants applying for the full subsidy of CNP-obtained naloxone must attest to the following: