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Tennessee Syringe Services Program (SSP) Application For Local Health Department Operated Programs

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 to ensure compliance with Tenn. Code Ann. § 68-1-136.

Upon a petition by the county legislative body, a county or district health department may establish and operate a needle and hypodermic syringe services program. The objectives of the program shall include all of the following:

Reduce the spread of human immunodeficiency virus (HIV), viral hepatitis, and other bloodborne diseases in this state;
Reduce needle stick injuries to law enforcement officers and other emergency personnel;
Encourage persons who inject drugs to enroll in evidence-based treatment; and,
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.

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

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

New application

Amended application (previously submitted and approved)

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Name of the organization or agency:

* must provide value

Name of the syringe services program, if different:

Primary contact information

Primary contact name:

* must provide value

Primary contact phone number:

* must provide value

Primary contact email address:

* must provide value

Secondary contact information

Secondary contact name:

Secondary contact phone number:

Secondary contact email address:

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

* must provide value

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 out of a vehicle at TDH approved location

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

* must provide value

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.

* must provide value

Upload file

Attached, please find an example of a map that documents an SSP location that meets the 2,000 feet 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.).

Upload file

Please confirm that the SSP's location complies with the zoning requirements in Tenn. Code Ann. § 68-1-
136(g).

* must provide value

I confirm the SSP's location complies with the the zoning requirements in Tenn. Code Ann. § 68-1-136(g).

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Please confirm that unused syringes and other injection supplies will be offered at no cost and in quantities sufficient to ensure that syringes other injection supplies are not shared or reused. See Tenn. Code Ann. § 68-1-136(b)(2).

* must provide value

I confirm that unused syringes and other injection supplies will be offered at no cost and in quantities sufficient to ensure that syringes other injection supplies are not shared or reused.

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

* must provide value

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:

* must provide value

Please confirm that the SSP's needle exchange policy will reflect the program striving for a 1-to-1 exchange. See Tenn. Code Ann. § 68-1-136(b)(2).

* must provide value

I confirm the SSP's exchange policy will reflect the program striving for a 1-to-1 exchange.

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Per Tenn. Code Ann. § 68-1-136(j), please confirm that the SSP will be fully funded by the county legislative body.

* must provide value

I confirm that the SSP will be fully funded by the county legislative body.

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

* must provide value

Purchase directly from manufacturer

Purchase from third-party vendor

Other:

If Other, please specify:

* must provide value

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 the health department will develop, implement, document and main a process for community engagement related to harm reduction and distribution and collection of needles and syringes.

* must provide value

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

* must provide value

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Describe the health department's experience collecting and reporting data.

* must provide value

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Describe the health department's current practices used to protect confidentiality of clients records and data.

* must provide value

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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.

* must provide value

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).

* must provide value

Upload file

A copy of the petition by the county legislative body to the county or district health department for the establishment and operation of the syringe services program must accompany this application. Please click here to upload the petition.

* must provide value

Upload file

Letters of support from 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.

* must provide value

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 the health department 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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