Naloxone Distribution Program Eligibility Application

Thank you for your interest in naloxone distribution. In order to participate in the Ontario Naloxone Program, your organization must meet specific eligibility criteria. Once you complete this application, a representative from Durham Region Health Department will contact you.

Agency contact information:

Agency Name

First Name (lead naloxone contact)

Last Name (lead naloxone contact)

Address

City

Postal Code

Phone Number

Email Address

What geographical area(s) does your agency serve?

Ajax

Brock

Clarington

Oshawa

Pickering

Scugog

Uxbridge

Whitby

Please describe the population that your agency serves (primary target population):

Does your agency reach difficult to reach (priority) populations where there is known drug use/opioid activity?

Yes

No

Does your agency work directly with populations at risk of opioid overdose?

Yes

No

Has your agency had requests for naloxone?

Yes

No

Can your agency commit to and sustain naloxone distribution? (eg: Does your organization have adequate staffing capacity, storage space)

Yes

No

Can your agency commit to collecting regular data and reporting back to Durham Region Health Department on a monthly basis?

Yes

No

Does your agency have WSIB or private insurance?

Yes

No

Is there any additional information you would like to share with Durham Region Heath Department regarding your agency’s need for naloxone?

Information is collected and used under the authority of the Health Protection and Promotion Act R.S.O. 1990 cH.7, s.5. This information is collected and used for the purposes of substance use prevention and harm reduction, reporting and ensuring eligibility for the program. Questions about this collection and use of information should be addressed to Durham Region Health Department, Manager, Health Information, Privacy and Security at 605 Rossland Rd E., P.O. Box 730, ON, L1N 0B2, (905) 668-7711.