Save Lives Oregon Harm Reduction Clearinghouse Application

Save Lives Oregon

Harm Reduction Clearinghouse

Application

Thank you for your interest in the Save Lives Oregon (SLO) Harm Reduction Clearinghouse Project!

The SLO Harm Reduction Clearinghouse offers no cost harm reduction supplies intended to prevent overdose, infection and injury related to substance use agencies across Oregon and Tribal communities. Participating organizations that meet the project's eligibility criteria and whose applications are approved, can order a variety of supplies from the project's approved supply list.

Eligibility criteria is based on agency type as well as current and/or planned activities. For more details, please select your agency's type in the dropdown menu to the right. Please allow 1-2 weeks after application submission for follow up email from info@savelivesoregon.org.

In addition to supply support, participants can access free technical assistance from experienced community partner programs.

Any questions about the application should be directed to info@savelivesoregon.org.

Begin Application Here

Please choose the organization category that best fits your agency type from the dropdown list below:

Select or enter value

Schools/Colleges/Universities

Find the application here: https://app.smartsheet.com/b/form/be322b3552dc43b081d9df813e4bb89a

Special District Category

Special Districts in the following categories – Fire/EMS, Hospital/Health Center, Library, Parks and Recreation, Ports and Transit – are eligible to access no cost harm reduction supplies.

There are two tracks for Special Districts to meet eligibility criteria:

TRACK 1: For special districts that need naloxone for staff to carry in the event of an onsite overdose emergency AND to hand out to people at highest risk of overdose, injury, or infection

TRACK 2: For special districts that need naloxone only for staff to carry in the event of an onsite overdose emergency.

**Upon acceptance into the Clearinghouse, all special districts are assigned a dollar amount to be spent on supplies offered through the Project. Special districts opting for Track 1 will receive a larger amount of funds to spend on supplies due to distribution efforts. Supplies available to order include:

Naloxone (both nasal and intramuscular)
Sharps containers
Syringes
Wound care supplies
Hygiene supplies
Safer sex supplies
PPE (masks, gloves, CPR shields)

**Special districts will be required to report distribution of naloxone, syringes and sharps containers. Additionally, for organizations ordering syringes for distribution, we will ask for a syringe collection, storage and disposal plan.

Select or enter value

Plan to hand supplies directly to community members?

Select "Yes" if the special district needs naloxone for staff to carry in the event of an onsite overdose emergency AND to hand out to people at highest risk of overdose, injury, or infection due to drug use.

Select "No" if the special district needs naloxone only for staff to carry in the event of an onsite overdose emergency.

Select or enter value

Organization Information

All Other Agency Eligibility Criteria

Applicant types outlined below are eligible to receive no cost supplies from the Clearinghouse when they agree to distribute directly to people who are using substances or people who are at high risk for overdose.

Community-based organizations with 501(c)(3) status or 501(c)(3) fiscal sponsorship
Harm Reduction and Syringe Service Programs within Community Health Clinics, FQHCs, Local Public Health Authorities
Tribal community and health care programs that serve people who use drugs
Withdrawal management, residential and outpatient substance use disorder treatment programs for clients who are waitlisted, dismissed, or leave
Uniformed First Responder agencies implementing ‘Leave Behind’ naloxone distribution programs
Jails providing release packets that include naloxone and/or other harm reduction supplies to people who may be at risk of overdose when they are released

Supplies available to order include:

Naloxone (both nasal and intramuscular)
Sharps containers
Syringes
Wound care supplies
Hygiene supplies
Safer sex supplies
PPE (masks, gloves, CPR shields)

Participating organizations will be required to report distribution of the naloxone, syringes and sharps containers.

Additionally, for organizations ordering syringes for distribution, we will ask for a syringe collection, storage and disposal plan.

Entity Legal Name

Organization/Entity Registry Number

The Registry Number is listed on the Secretary of State Business Entity Data page. The number can be located using the "Find a Business" Search function on the Oregon Secretary of State webpage https://sos.oregon.gov/business/Pages/find.aspx

Organization EIN or FIN

Employer Identification Number / Federal Identification Number

Organization and Program Types (Please check all that apply.)

Select

Please describe the organization type

Does the organization provide direct services to people who are at risk of overdose or infections related to substance use?

Select

Does the organization use a "Doing Business As" (DBA) name?

Organization Doing Business As (DBA) name

Please list the organization DBA name

Does the organization have a fiscal sponsor?

Fiscal sponsor name

Please provide the name of the organization's fiscal sponsor.

Application Contact Name

The person that Oregon Health Authority (OHA) can contact if there are questions about this Clearinghouse application.

Application Contact Phone*

Phone

Application Contact Email

Application Authorized Signature Name

The person at your agency who is authorized to submit applications for program funding or support.

Authorized Signature email

Organization mailing address - Street

Organization mailing address - City

Organization mailing address - State

Organization mailing address - ZIP Code

Organization/Program Service Areas and Activities

The Oregon counties or service areas where supplies will be used or distributed. (Please select all that apply.)

Select

Please describe the other service areas where supplies will be used or distributed.

Please share the populations, groups or communities that the organization or program engages and/or will provide supplies.

Please describe the language capabilities of program staff and volunteers.

Participant material format, development and translation needs

If materials are developed for the project, are their specific formats, languages or translation needs for the communities, groups or people your organization or program engages?

Please indicate the organization's activities and services that will be supported by these supplies. (Please select all that apply.)

Select

Please describe "Other" activities or services.

Are the supplies going to be used to support new activities or services?

New activities or services are ones that have not started as of the date this application is submitted.

Select

Please indicate which activities or services are new activities. (Please select all that apply.)

Select

Please describe "other" new activities or services.

Please estimate the number of unduplicated people per month who will receive supplies by your organization or program.

Program Supply Type

Please indicate the general types of supplies your agency plans to order through the Save Lives Oregon Harm Reduction Supply Clearinghouse. (Please select all that apply.)

Select

Program Experience

Participating organizations will be required to report distribution of naloxone, syringes and syringe disposal containers.

Does your organization have a process in place to count and report naloxone distribution?

Select

Does your organization have a written procedure for naloxone refills?

Does your agency have a process in place for naloxone refills and community overdose reversal reports? You can request technical assistance to support your agency to develop naloxone distribution and refill plans and forms.

Select

Does your organization have a process in place to report the number of syringes distributed?

Select or enter value

Does your organization or program have a written syringe collection and disposal plan?

Select

Please upload your syringe disposal plan

Drag and drop files here or

Organization's funding experience (Please check all that apply.)

Please indicate if your organization or program receives funding directly from the Oregon Health Authority (OHA).

Select

Please describe the "other" experience with OHA funding.

Technical Assistance

Technical Assistance is a type of focused support to build the capacity of an organization or program. The purpose of the technical assistance available through this project is to build participating organization's capacity to set-up, conduct and report on the overdose prevention and harm reduction activities and programs.

Would your agency or program like to request Technical Aasistance (TA) with your order or program activities?

Select or enter value

What type(s) of activities would you like technical assistance to support? (Please check all that apply.)

Select

Supply Shipping information

The shipping address must meet the following criteria:

CANNOT be a Post Office Box.

Must be zoned business (as opposed to a residential)

Needs to be a location suitable for a large box or pallet delivery.

Someone is available to receive/sign for deliveries at least one day M-F, between at minimum 9am and 3pm.

Ship to Address

Physical business address only. No PO boxes allowed.

Ship to Address - City

Ship to Address - State

Ship to Address - ZIP code

Ship to Contact Name

This is the name of the person that the delivery company can contact with questions or issues related to delivery.

Ship to Contact Email

Ship To Contact Phone

Phone

Ship to Site Delivery Days

These are the days someone at your agency is available to receive/sign for a delivery. *At minimum one day between Monday and Friday*

Ship to Site Delivery Hours

These are the hours someone at your agency is available to sign for a delivery. *At minimum 9am to 3pm, PST*

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