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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?
da757946e74441a39ec90c065045388b Updating information 
da757946e74441a39ec90c065045388b New agency 
Please select which program you are registering you agency for:
Check all that apply
da757946e74441a39ec90c065045388b Epi-Auto Injector 
da757946e74441a39ec90c065045388b Naloxone 
Who is filling out this form?
Today's Date:
v
Agency Name:
Full Agency Name (no abbreviations)
Agency Address:
Primary address for the agency
Street Address
City
County
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:
d32941412577446faf268deb00414699 Licensed 
d32941412577446faf268deb00414699 Non-Licensed 
Anticipated date of completion for training:
v
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.
d32941412577446faf268deb00414699 I Agree 
d32941412577446faf268deb00414699 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.
da757946e74441a39ec90c065045388b I Agree