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Tennessee Syringe Services Program (SSP) Application

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Complete and submit the following Syringe Services Program application. The SSP must be approved by the Tennessee Department of Health prior to commencement of operations.

Any organization (such as a community-based organization or health department) that promotes scientifically proven ways of mitigating health risks associated with drug use, may establish and operate a needle and hypodermic syringe services program. The objectives of the program shall be to do all of the following:

1. Reduce the spread of human immunodeficiency virus (HIV), viral hepatitis, and other bloodborne diseases in this state;

2. Reduce needle stick injuries to law enforcement officers and other emergency personnel;

3. Encourage persons who inject drugs to enroll in evidence-based treatment; and

4. Provide overdose prevention services, including access to naloxone.

The Tennessee Department of Health (TDH) is required by law to approve all organizations seeking to establish and operate a needle and hypodermic syringe services program. All applicants are required to fully complete the application and provide the requested information per §T.C.A Title 68, Chapter 1.

For questions, please contact SSP.Health@tn.gov.

Please see the PDF version of the Tennessee Department of Health syringe services program application for review.

Attachment:

TN SSP Application.pdf

Please complete and submit the following information. All of the fields are required. Once it is submitted, the SSP Coordinator will contact you within 3 business days to confirm receipt of the SSP application.

Is this a new or amended syringe services program (SSP) application?

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New application

Amended application (make changes to a previously approved application)

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Name of the organization or agency:

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Primary contact information

Primary contact name:

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Primary contact phone number:

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Primary contact email address:

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Secondary contact information

Secondary contact name:

Secondary contact phone number:

Secondary contact email address:

Type of syringe services program (check all that apply):

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Fixed site: SSP is located in a building or specific location, such as a storefront, office, or other space with street-level access

Mobile site: SSP is operated from a van, bus, or other mobile unit to deliver services (at pre-approved locations)

Will the newly proposed SSP be located in a different county from current operations?

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Yes

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Every SSP location must meet the legislation's zoning requirements and be approved by TDH. Please download and complete the SSP location table.

Attachment:

SSP location table.docx

Please upload the completed SSP location table.

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Upload file

Attached, please find an example of a map that documents an SSP location that meets the SSP zoning requirements.

Attachment:

2,000 feet SSP application map example.jpg

Please upload documentation that the proposed SSP location(s) meets the legislation's zoning requirements (i.e. Google maps, GIS, etc.).

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Upload file

Please note that the law requires that unused syringes and other injection supplies, be supplied at no cost and in quantities sufficient to ensure that syringes other injection supplies are not shared or reused. No public funds may be used to purchase syringes, needles, or cookers.

Population(s) served by the program (check all that apply):

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Persons who inject drugs

Persons who use insulin

Persons who use sex hormone injections/hormonal therapy injections

Persons who use HIV/HCV medication injections

Persons who use human growth hormones and steroids

Other:

If Other, please specify:

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How will your syringe services program dispose of used needles and hypodermic syringes? (check all that apply)

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Biohazard company (please list)

Clinic or hospital (please list)

Other:

Please specify biohazard company:

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Please specify clinic or hospital:

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If Other, please specify:

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Per §T.C.A Title 68, Chapter 1, please confirm that the SSP's needle exchange policy will operate under a strive for 1-to-1 exchange policy.

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Yes, the SSP will operate under a strive for 1-to-1 exchange policy.

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How will your agency access sterile needles and syringes? (check all that apply)

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Purchase directly from manufacturer

Purchase from third-party vendor

Other:

If Other, please specify:

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Applicants must demonstrate the level of community readiness and administrative capacity for provision of harm reduction services, including syringe services. Below, please describe the organization's capacity to fulfill the following requirements.

Describe how your agency will develop, implement, document, and maintain a process for community engagement related to harm reduction and distribution and collection of needles and syringes.

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Describe related health and/or behavioral health services your agency currently provides and the number of years these services have been provided.

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Describe your agency's experience collecting and reporting data.

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Describe your agency's current practices used to protect confidentiality of clients, records, and data.

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The law requires reasonable and adequate security of program sites, equipment, and personnel. Please upload the program's security and confidentiality policies and procedures.

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Upload file

Documentation of safety and security plan submission to local law enforcement is required. Please click here to upload this documentation (e.g., original email with confirmation of receipt).

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Letters of support from county health department, local law enforcement, and/or governing body are strongly encouraged to demonstrate and ensure community cohesion, but they are not required. Please click here to upload optional letter(s) of support.

Upload file

Tennessee law protects SSP employees, volunteers, and participants from being charged with possession of syringes or other injection supplies, including those with residual amounts of drugs present, if obtained or returned to an SSP. This immunity only applies to a participant's possession when the participant is engaged in the exchange or in transit to or from the exchange. Persons affiliated with an SSP must provide written verification (such as a participant card) to the arresting officer or law enforcement agency to be granted limited immunity. The SSP law does not specify verification format or content. Please upload an example of the proposed participant verification card.

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Upload file

For reference, please find an example of a participant ID card attached.

Attachment:

STEP TN Participant ID Card Example.pdf

Please download and complete the attached to document how your agency will provide services by completing the checklist below. If the applicant is unable to identify a referral source for one or more services, please provide a description of efforts that will be made to identify service providers. This will assist TDH with developing technical assistance and capacity building to ensure required services are available.

Attachment:

SSP services table.docx

Please upload the completed SSP services to be provided table.

* must provide value

Upload file

Note: The SSP must be approved by the Tennessee Department of Health prior to commencement of operations.

Questions can be directed to SSP.Health@tn.gov or (615) 741-7500.

In order to maintain permission to continue to run your program, the Tennessee Department of Health (TDH) requires that all syringe services programs submit an annual report to TDH no later than March 1st of every year for the activities conducted during the preceding calendar year. The annual reporting form can be found on the TDH website at https://redcap.link/TDHSSPAnnualReporting.

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