NYC Overdose Prevention Supplies Order Form

This form is for New York City (NYC) Opioid Overdose Prevention Programs (OOPPs). If you have any questions, please contact the NYC Department of Health and Mental Hygiene at reports@health.nyc.gov.

The average time for order processing and shipping is 3-4 weeks from the time you submit this order form. If this is the first-time ordering supplies to a new Ship to Address, please anticipate a longer processing time.

Today's date

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M-D-Y

OOPP Information

OOPP information below should match what is listed on your OOPP registration in nyoverdose.org.

To update your program information, such as your Clinical Director or Program Director, please email overdose@health.ny.gov with requested changes (include: name, title, email, medical license, etc.)

OOPP Name

* must provide value

OOPP Certificate Number

* must provide value

OOPP Clinical Director

* must provide value

OOPP Program Director

* must provide value

Ship to Contact Information for this Order

Ship to information below should match what is listed as a ship-to-site on your OOPP registration in nyoverdose.org as naloxone and fentanyl test strip (FTS) supplies can only be shipped to sites listed.

Instructions for how to update or add a ship-to-site on nyoverdose.org can be found here.

Site Name

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Ship To Name:

Please indicate a name that is easily recognizable at your site to avoid orders being sent back.

* must provide value

Ship To Email Address:

This email address will be used to send confirmation emails and any questions or delivery issues regarding this order.

* must provide value

Ship To Address: Line 1

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Ship To Address: Line 2 (optional)

e.g. suite #, Floor #, attention to staff name on site

City:

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State:

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Zip Code:

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Ship to Phone Number:

Please enter only numbers. Entries with symbols (e.g. parentheses or hyphens) or spaces will not be accepted.

* must provide value

Ship to Phone Extension (optional)

Order Information

Please specify the amount of each supply you would like to order.

Number of Narcan boxes

Must be ordered in multiple of 48 boxes. Each box of Narcan = 2 doses = 1 kit.

* must provide value

Number of blue bags (for Narcan)

Must be ordered in multiples of 48. Blue bags are pre-packed with gloves, rescue breathing mask and Spanish/English Naloxone Educational insert.

* must provide value

Number of intramuscular (IM) naloxone boxes

Must be ordered in multiple of 25 boxes. Each box = 2 doses/ 2 syringes = 1 kit.

* must provide value

Number of blue bags (for intramuscular)

Must be ordered in multiples of 25. Blue bags are pre-packed with gloves, rescue breathing mask and Spanish/English Naloxone Education Insert. Shipped with Intramuscular Naloxone instruction booklets and alcohol swabs.

* must provide value

Number of blue cards (Certificate of Completion)

Must be ordered in multiples of 50. Dispense 1 card per kit.

* must provide value

Number of Fentanyl Test Strip (FTS) boxes

Must be in orders of 100. Each box of FTS = 100 strips = 50 kits.

* must provide value

Number of Fentanyl Test Strip Instructional Brochures "How to test your drugs using Fentanyl Test Strips" in ENGLISH

Must be in multiples of 100. 1 brochure= 1 kit.

Number of Fentanyl Test Strip Instructional Brochures "How to test your drugs using Fentanyl Test Strips" in SPANISH

Must be in multiples of 100. 1 brochure= 1 kit.

Please note: We are unable to process orders of only FTS brochures. Please contact 311 or reach out to naloxone@health.nyc.gov for further assistance.

Current Naloxone Inventory

Inventory questions are currently optional, but may be required in the future (with advanced notice).

How many unexpired naloxone kits are in stock at this site?

How many expired naloxone kits are in stock at this site?

Urgency of Request

If this order request is urgent, please indicate why. If this order is not urgent, leave as "Not Urgent".

Please indicate the reason for the urgent request

* must provide value

Expand

Attestation

By checking this box, I affirm that the program and clinical director of this Opioid Overdose Prevention Program have authorized this order of naloxone to be shipped to the address above.

* must provide value

If you have any questions about your order, please contact the NYC Department of Health and Mental Hygiene at reports@health.nyc.gov.
Please include your OOPP name and cert number in your subject line and the date you ordered and record ID in the body.

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