Policies
Title | Short Description | Doc | |
---|---|---|---|
Eligibility Criteria for Medications used to treat Opiate Use Disorder Policy 13-01 | Eligibility criteria and reporting policy for those prescribed suboxone or methadone while in SARP. | DOCX | |
Eligibility for Initial Admission Policy 18-03 | Describes the SARP eligibility criteria for admission. | DOCX | |
Staff Action Authority Policy 99-06 | Allows SARP staff to act on admission, termination, agreement amendment, international travel requests, program transfer, and discharge matters. | DOC | |
Participants Reentry Into Monitored Practice Policy 18-01 | Establishes eligibility criteria for re-entry into monitored nursing practice. | DOCX | |
Activation of License Suspension Provisions Policy 17-01 | Expedites actions on nursing license in circumstances of a SARP participant poses a risk. | DOCX | |
Confidentiality for SARP Applicants Policy 12-01 | Confidentiality of information and records. | DOC | |
Unauthorized Substance Use or Impairment During Program Participation Policy 06-01 | Identifies criteria for SARP staff to act in response to a participant events. | DOCX | |
Medical Waiver Policy 99-04 | Process for waiver if a participant is temporarily unable to comply with the Consent Agreement. | DOCX |
Documents for current participants
Quarterly monitoring
Title | Short Description | DOC | |
---|---|---|---|
Quarterly Monitoring Checklist | Quarterly monitoring document face sheet checklist. | DOC | |
Therapist Report Form | Therapist report form submitted by the established therapist. | DOC | |
Nurse Employment Primary Supervisor Report | Report form submitted by the primary supervising nurse at place of employment. Only applies if working in a nursing role. | DOC | |
Group Attendance Log | Weekly group attendance log that documents participation in groups. | DOC | |
Prescriber Report for Medications to Treat Opiate Use Disorder | Completed by the prescriber that prescribes a medication to treat opioid use disorder (suboxone or methadone). | DOC |
Employment review application forms
Title | Short Description | Doc | |
---|---|---|---|
SARP Employment Review Form | Completed by participants that describes employment opportunity. Submitted after an interview when prospective employer elects to move forward with hiring process. | DOC | |
Supervisor Verification and Agreement to Monitor Practice Form | Individually completed by all prospective supervisors assigned to supervise while on site at place of employment. | DOC | |
Release of Information Form | DPH release of information form that allows SARP staff to speak with individuals identified in the form. May include multiple people on one form. For employment review, usually includes members from interview team: HR personnel, DON/RN manager, etc. | DOCX |
Additional forms
Title | Short Description | Doc | |
---|---|---|---|
CASP Amendment Request Form | Submitted when petitioning for nursing privileges, changing frequency of therapy appointments, and other requests | DOC | |
Authorization for Release of Information | DPH release of information form that allows SARP staff to speak with individuals identified in the form. Please identify specific individuals and not entire organizations. May include multiple people on one form. | DOCX | |
New Prescription Submission Form | Submitted when reporting start of any new medication while in SARP. | DOC | |
Suboxone/Methadone Prescriber Monitoring Report Form | Completed by the prescriber that prescribes either suboxone or methadone. Submitted to SARP staff on a quarterly basis. | DOC | |
International Travel Request Form | Submitted when seeking to gain approval for international travel prior to solidifying travel plans. | DOC | |
Medical Waiver Application Form | Submitted prior to a planned healthcare event when SARP participation has been disrupted. May be submitted after an unplanned event. | DOC | |
Transfer Attestation Form | Submitted when seeking to transfer to a monitoring program managed by another state. | DOC | |
Discharge Petition Form | Submitted when petitioning to discharge from SARP near discharge date. | DOC |
Contact for Substance Addiction Recovery Program (SARP) documents
Phone
SARP Confidential phone line
Call Board of Registration in Nursing, SARP Confidential phone line at (617) 973-0904
Fax
Board of Registration in Nursing
617-973-0984
Board of Registration in Nursing - SARP
617-887-8786