1. Certifies that the contact and location information provided is correct.
2. Will ensure that any of its affiliates or subcontractors apply for their own standing order.
3. Agrees to allow the California Department of Public Health to contact the entity using the information provided on the application form.
4. Agrees to allow the California Department of Public Health to use the information provided on the application form to track the use of the standing order and conduct other public health and epidemiological surveillance activities.
5. Acknowledges that the standing order cannot be used to sell naloxone.
6. Agrees to ensure that entities and individuals receiving and administering naloxone receive opioid overdose prevention and treatment training.
7. Agrees to maintain and report, at the time of renewal, information regarding the number of doses of naloxone distributed under this standing order.
8. If known/available, agrees to maintain and report information, upon renewal, regarding the number of reversals that occurred using naloxone distributed under this standing order.
9. Agrees to re-register for the standing order if there is a change in the information required on this form.
10. Agrees to maintain a copy of the standing order, which will include these terms and conditions.