This form is for WAQRR-accredited providers to order NARCAN (Naloxone) for their recovery residences. Each accredited house is eligible to order one box of NARCAN. In cases where additional NARCAN is needed, please provide a detailed reason for the request, including information on previous use.

Instructions:

1. Provider Information: Fill in the provider name, contact email, phone number, and the name and address of the house where NARCAN will be used.

2. Number of Boxes: Check the box if you are requesting the standard 1 box of NARCAN per accredited house.

3. Additional Requests: If you need more than one box, complete the section titled "Reason for Request if Additional Box Ordered." You must provide:

   • The reason for needing extra NARCAN.
   • Information on prior NARCAN use, including:
     • Who it was used on (e.g., resident, visitor).
     • Whether the overdose reversal was successful.

4. Comments: Add any additional relevant information in the comments section if needed.

5. Signature & Date: The form must be signed electronically and dated by the provider requesting the NARCAN.

Important Notes:

• Limit of 1 box per accredited house unless otherwise justified.
• Accurate and complete information must be provided for any additional requests.

NARCAN is a vital tool in preventing overdose deaths, and proper reporting ensures continued support for your recovery residence.