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?
298c5ca2f9e94f3a9c7b2732d364be3e Updating information 
298c5ca2f9e94f3a9c7b2732d364be3e New agency 
Please select which program you are registering you agency for:
Check all that apply
298c5ca2f9e94f3a9c7b2732d364be3e Epi-Auto Injector 
298c5ca2f9e94f3a9c7b2732d364be3e Naloxone 
Who is filling out this form?
Today's Date:
Agency Name:
Full Agency Name (no abbreviations)
Agency Address:
Primary address for the agency
Street Address
Zip 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:
c0a67afa77384964b42672f78be53c1b Licensed 
c0a67afa77384964b42672f78be53c1b 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.
c0a67afa77384964b42672f78be53c1b I Agree 
c0a67afa77384964b42672f78be53c1b 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.
298c5ca2f9e94f3a9c7b2732d364be3e I Agree