NY Overdose Response Strategy (ORS) Team
Law Enforcement Leave Behind Naloxone Registration and
Technical Assistance Form

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.

Question Title

1. Name (Required.)

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2. Law Enforcement Agency Name (Required.)

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3. Title (Required.)

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4. What is the size of your law enforcement agency? (Required.)

Under 50

50-100

101-249

250+

Other (please specify)

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5. Contact Information (Required.)

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6. Which county is your agency located in? (Required.)

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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) (Required.)

Yes, please register my agency as an operational LBN program

No, we are seeking technical assistance to implement LBN

NY Overdose Response Strategy (ORS) TeamLaw Enforcement Leave Behind Naloxone Registration andTechnical Assistance Form

Question Title

* 1. Name (Required.)

Question Title

* 2. Law Enforcement Agency Name (Required.)

Question Title

* 3. Title (Required.)

Question Title

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

Question Title

* 5. Contact Information (Required.)

Question Title

* 6. Which county is your agency located in? (Required.)

Question Title

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

NY Overdose Response Strategy (ORS) Team
Law Enforcement Leave Behind Naloxone Registration and
Technical Assistance Form

1. Name (Required.)

2. Law Enforcement Agency Name (Required.)

3. Title (Required.)

4. What is the size of your law enforcement agency? (Required.)

5. Contact Information (Required.)

6. Which county is your agency located in? (Required.)

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