This form is for NYS law enforcement agencies to either register their operational Leave Behind Naloxone (LBN) Program with the NY ORS Team and/or to indicate interest in receiving technical assistance in implementing a LBN program.
If requesting technical assistance, the NYS ORS Team will respond within 24-48 hours to make arrangements to discuss your needs and provide LBN implementation support, including but not limited to connection to a local naloxone source, state and local resources and/or assistance in developing standard operating procedures.

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* 1. Name

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* 2. Law Enforcement Agency Name

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* 3. Title

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* 4. What is the size of your law enforcement agency?

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* 6. Which county is your agency located in?

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* 7. Is your agency currently implementing Leave Behind Naloxone? (i.e., officers are distributing naloxone kits, agency training and policy plan in place)

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