Substance Addiction Recovery Program (SARP) documents

SARP policies and all required documents for current program participants

Table of Contents

Policies

Title Short Description PDF 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. PDF DOCX
Eligibility for Initial Admission Policy 18-03 Describes the SARP eligibility criteria for admission. PDF 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. PDF DOC
Participants Reentry Into Monitored Practice Policy 18-01 Establishes eligibility criteria for re-entry into monitored nursing practice. PDF DOCX
Activation of License Suspension Provisions Policy 17-01 Expedites actions on nursing license in circumstances of a SARP participant poses a risk. PDF DOCX
Confidentiality for SARP Applicants Policy 12-01 Confidentiality of information and records. PDF 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. PDF DOCX
Medical Waiver Policy 99-04 Process for waiver if a participant is temporarily unable to comply with the Consent Agreement. PDF DOCX

Documents for current participants

Quarterly monitoring

Title Short Description PDF DOC
Quarterly Monitoring Checklist Quarterly monitoring document face sheet checklist. PDF DOC
Therapist Report Form Therapist report form submitted by the established therapist. PDF 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. PDF DOC
Group Attendance Log Weekly group attendance log that documents participation in groups. PDF 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). PDF DOC

Employment review application forms

Title Short Description PDF 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. PDF 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. PDF 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. PDF DOCX

Additional forms

Title Short Description PDF Doc
CASP Amendment Request Form Submitted when petitioning for nursing privileges, changing frequency of therapy appointments, and other requests PDF 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. PDF DOCX
New Prescription Submission Form Submitted when reporting start of any new medication while in SARP. PDF 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. PDF DOC
International Travel Request Form Submitted when seeking to gain approval for international travel prior to solidifying travel plans. PDF 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. PDF DOC
Transfer Attestation Form Submitted when seeking to transfer to a monitoring program managed by another state. PDF DOC
Discharge Petition Form Submitted when petitioning to discharge from SARP near discharge date. PDF DOC

Contact   for Substance Addiction Recovery Program (SARP) documents

Fax

Board of Registration in Nursing 617-973-0984
Board of Registration in Nursing - SARP 617-887-8786

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