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2022 BLS Agency Registration Form for Naloxone and Epi Auto-Injector

This form should be filled out by BLS agencies registering or updating information for the Naloxone or Epi-Auto Injector Programs.

If your agency has a new primary contact, medical command physician or demographics, please complete this form.

Are you filling out this form to provide updated information, or are you a new agency?

Updating information

New agency

Please select which program you are registering you agency for:

Check all that apply

Epi-Auto Injector

Naloxone

Who is filling out this form?

First name
Last name
Email	Email is already used by another user
Phone 1

Today's Date:

Agency Name:

Full Agency Name (no abbreviations)

Agency Address:

Primary address for the agency

Street Address	An answer is requiredStreet Address
City	An answer is requiredCity
County	An answer is requiredCounty
Zip Code	An answer is requiredZip Code

Agency Phone Number:

Agency Email:

Name of Primary Contact Person for the Agency:

Primary Contact Person's Phone Number:

Primary Contact Person's Email:

Business Type:

Licensed

Non-Licensed

Anticipated date of completion for training:

I understand (under N.J.S.A. 26:2K-67) all administrations of medication must be documented in a NEMSIS compliant electronic Patient Care Report (ePCR) that is transmitted to the Department.

Medication must be documented within the medication section (eMedication.03) of the ePCR.

I Agree

I Disagree

What ePCR software does your agency use?

(example: emsCharts, Zoll, Emergency Reporting etc.)

I affirm that all information listed above is true and correct to the best of my knowledge. Additionally, all providers of the above listed agency that will utilize the medication(s) shall have received proper training prior to administration and will report use of the medication as required by local and State policy and regulations.

I Agree