DOH-4391 (6/15) Page 3 of 3
NEW YORK STATE DEPARTMENT OF HEALTH
AIDS Institute
Opioid Overdose Prevention Program Registration
The Program Director will manage and have overall responsibility for the program and shall - either directly or by delegation -
be responsible for the following:
• identifying the clinical director, who in turn has overall clinical oversight for the program;
• establishing the program’s training curriculum consistent with guidance from the Department of Health;
• identifying and training other program staff;
• selecting the trained overdose responders;
• issuing certificates of completion to those responders who have successfully completed the program’s training
curriculum, except these certificates of completion are not required for public safety or firefighting personnel:
• establishing and maintaining the program’s recordkeeping system;
• ensuring that all trained overdose responders successfully complete the training curriculum;
• being a liaison, where appropriate, with emergency medical services and emergency dispatch agencies;
assisting the clinical director in reviewing reports of overdose responses by trained overdose responders, particularly
those involving administration of naloxone;
• reporting administrations of naloxone by trained overdose responders on forms which the Department mandates,
however where public safety and firefighting personnel are involved, they do their reporting directly to the Department; and
• reporting on a quarterly basis the number of doses of naloxone provided and the number of overdose responders trained.
The Clinical Director, who must be a physician, physician assistant or nurse practitioner, has clinical oversight for the program
and is responsible for the following:
• providing clinical consultation, expertise and oversight;
• serving as a clinical advisor and liaison concerning medical issues related to the program;
• providing consultation to ensure that all trained overdose responders are properly trained;
• adapting and approving opioid overdose prevention training curriculum content and protocols;
• reviewing reports of all administrations of naloxone;
• prescribing naloxone; and
• designating individuals who are authorized to dispense or furnish naloxone to trained overdose responders and/or
individuals who are responsible for ensuring orderly, controlled, shared access to an identifiable pool of trained
overdose responders pursuant to a non-patient specific prescription.
The following must be available for inspection by the Department:
• the names of trained overdose responders, the dates they were trained, and the dates they were furnished naloxone
• copies of program policies and procedures;
• copy of the contract/agreement with the Clinical Director, if appropriate;
• opioid antagonist administration usage reports and forms;
• documentation of review of administration of an opioid antagonist;
• an inventory of overdose response supplies.
Program Director: Signature______________________________________________ Date _______________________
Clinical Director: Signature______________________________________________ Date _______________________
Note: Submission of a completed Opioid Overdose Prevention Program Registration (DOH 4391) does not constitute registration until
the NYS Department of Health issues a certificate of approval. Questions regarding registration should be directed to: (212) 417-4770
Submit completed Opioid Overdose Prevention Program Registration (DOH 4391) to:
Opioid Overdose Prevention
AIDS Institute, Division of HIV, HCV & STD Prevention
NYS Department of Health, Room 308, Corning Tower, Albany, New York 12237
click to sign
signature
click to edit
![]()
click to sign
signature
click to edit
![]()
