Fillable Facility Overdose Response Box Program Registration Form -

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Facility Overdose Response Box Program Registration Form -

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Facility Overdose Response Box Program –
Registration Form – Organization Version 4.0 May 2020
Date:
Organization Name:
Services Offered:
(check all that apply)
Drop-In
Emergency Shelter
Supportive Housing
Subsidized Housing
Outreach
Harm Reduction Supplies
Take Home Naloxone
Counselling
Other: ________________________
I AM AWARE THAT MY ORGANIZATION WILL BE PARTICIPATING IN THE FACILITY OVERDOSE RESPONSE BOX
PROGRAM
Executive
Director
Name:
Signature:
PLEASE DESIGNATE SOMEONE WITHIN YOUR ORGANIZATION TO COMMUNICATE WITH THE BC HARM REDUCTION
PROGRAM ABOUT SITE ELIGIBILITY AND APPROVAL AND MAJOR CHANGES TO THE REQUIREMENTS OF THE FACILITY
RESPONSE BOX PROGRAM.
Name:
Email:
Phone:
Please complete these forms and submit by E-MAIL to naloxone@bccdc.ca when enough staff have been trained to
ensure there is one staff member with the competencies to administer naloxone scheduled for every shift. If you don’t
have e-mail please fax to (604) 707-2516.
Your Initial Facility Overdose Response Box Order will not be sent until this form is received. Please allow at least 2-4
weeks for delivery of the initial order.
Facility Overdose Response Box Program
Registration Form - Organization
Complete this page IF first time registering your organization with the FORB program
Facility Overdose Response Box Program –
Registration Form – Site
Facility Overdose Response Box Program
Registration Form - Site
Date:
Affiliated Organization:
PLEASE PROVIDE THE FOLLOWING INFORMATION ABOUT YOUR SITE
Site Name:
Site Address:
Street
City/Town
Postal Code
Services Offered:
(check all that apply)
Drop-In
Emergency Shelter
Supportive Housing
Subsidized Housing
Outreach
Harm Reduction Supplies
Take Home Naloxone
Counselling
Other: ________________________
PLEASE PROVIDE ESTIMATES FOR THE FOLLOWING INFORMATION ABOUT YOUR SITE STAFF AND CLIENTS:
Number of Staff
Employed at Site
Full
Time:
Part
Time:
Volunteer/
Student:
Number of Clients Seen (Daily):
Estimated number of staff that will require training in naloxone administration:
(so we can provide you with training supplies)
PLEASE TELL US WHERE OVERDOSE RESPONSE SUPPLIES SHOULD BE SHIPPED TO:
Shipping Address
Street
City/Town
Postal Code
Delivery Days & Times
Special Instructions
PLEASE DESIGNATE SOMEONE AT YOUR SITE TO COMMUNICATE WITH THE BC HARM REDUCTION PROGRAM ABOUT
PROGRAM DOCUMENTATION AND REQUIREMENTS.
Name:
Email:
Phone:
Version 3.0 May 2020
Facility Response Box Program
New Site Agreement
Version 4.0 May 2020
Facility Overdose Response Box Program
New Site Agreement
My organization has:
addressed issues related to occupational health and safety and other risk issues related to
participation in the program.
the proper policies and procedures in place to support staff in responding to opioid overdoses,
including providing guidance for staff not trained/confident in administering naloxone.
My organization will:
implement and inform staff of the debriefing process for supporting staff following an overdose
response, and additional supports available to them.
develop an ongoing plan for training staff in overdose prevention, recognition and response,
including use of overdose practice drills and refresher trainings to maintain competency.
I, or my designate, will:
ensure ongoing compliance with Facility Overdose Response Box Program requirements.
be accountable to the BC Harm Reduction Program by promptly completing and submitting
required documentation after naloxone is used.
take full responsibility for training staff in overdose prevention, recognition and response
including administration of naloxone, and ensuring that staff that administer naloxone meet the
required competencies for participating in the program.
keep records of employees that have completed training and meet required competencies.
maintain employee competency through practice drills and refresher trainings.
ensure that all staff have basic training in overdose recognition (signs and symptoms) and
response (calling 911 and rescue breathing), even if not trained to administer naloxone.
ensure that newly hired employees receive training in overdose prevention, recognition and
response and have the required competencies before they can administer naloxone.
take full responsibility for monitoring the contents of the overdose response boxes to ensure
adequate supply levels and that the medication has not expired.
notify BCCDC of changes in Facility Overdose Response Box Program Contact Person or Site
Coordinators.
Name (Print):
Signature:
Position:
Date:
Organization:
Site:
click to sign
signature
click to edit
Facility Overdose Response Box Program
Training Agreement
Organization Name:
Site Name:
Please indicate at least one educator who has provided training on overdose prevention, recognition
and response to your staff.
Educator Name:
Job Title:
Educator Name:
Job Title:
Educator Name:
Job Title:
At my site, enough staff have been trained to ensure there is one staff member with the competencies
to administer naloxone scheduled for every shift.
I will submit the Summary Training Record when all planned staff training is complete.
Name (Print):
Job Title:
Signature:
Date:
Version 3.0 May 2020
Facility Overdose Response Box Program
Summary Training Record
Please complete the following form once you have finished staff training.
If additional staff are trained after this record has been submitted, please complete a new record
indicating only individuals trained since the previous record was submitted (i.e. please do not double
count people – do not count individuals a second time if they are re-trained).
Please submit the form even if your staff received their training before joining the Facility Overdose
Response Box Program. This information will help us evaluate the Facility Overdose Response Box
Program.
Date Training Began:
Date Form Completed:
Please record the number of individuals at your site that have the competencies for participating in
the Facility Overdose Response Box Program:
Managers/
Supervisors
Full-time
employees
Part-time/
casual employees
Volunteers/
Students
Total
Number
Trained:
Version 3.0 May 2020
Please E-MAIL to naloxone@bccdc.ca – If you don’t have e-mail please fax to 604-707-2516
FACILITY OVERDOSE RESPONSE BOX PROGRAM – INITIAL Supply Order Form
**Please allow up to two weeks for order delivery**
• These supplies are intended for use by staff at registered
FORB sites only.
• We provide both individual-sized fabric kits with 3 doses
and hard sided plastic tool boxes with 10 or 20 doses (see
image to right).
• If you have had no onsite ODs in the last year or if they are
rare we recommend either the 3 dose kit or 10 dose box.
• The 3 dose kits are ideal for outreach workers.
• A large facility may need more than 1 kit/box.
• If you have frequent onsite ODs and would like to order
additional naloxone to keep at your site, please
email naloxone@bccdc.ca to arrange
Please complete the initial order below to indicate which overdose response supplies you need for your
site. Additional orders will be submitted using the FORB supply re-order form.
Site Name and ID:
Date Submitted:
Contact Name:
Delivery Days
& Times:
Shipping Address (Including City and Postal Code):
**Shipping is by courier, must be physical location not PO Box**
Phone Number:
Special Delivery Instructions:
Products
Contents
Quantity
Facility Overdose
Response Kit (3 dose)
• 3 x Naloxone 1 mL ampoule with plastic ampoule breaker
• 3 x VanishPoint® syringe
• 1 x individual breathing mask| 1 x pair of gloves
Facility Overdose
Response Box (10 dose)
•
10 x Naloxone 1 mL ampoule with plastic ampoule breaker
• 10 x VanishPoint® syringe
•
10 x individual breathing mask | 1 x box of 200 gloves
Facility Overdose
Response Box (20 dose)
• 20 x Naloxone 1 mL ampoule with plastic ampoule breaker
• 20 x VanishPoint® syringe
• 20 x individual breathing mask | 1 x box of 200 gloves
Training
(loose supplies)
• VanishPoint® syringe
• Plastic ampoule breaker
• Water ampoule, 1mL
This form is only for approved sites participating in the Facility Overdose Response Box Program
May 2020
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Completed 8 January 2021

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