Partnership Commitment Form Test Page Partnership Commitment Form Partners and Commitment Step 1 of 2 50% Email(Required) Main Contact Name/Title(Required) First Last Position of Main Contact(Required) Chief/Executive Officer Program Supervisor (Sworn) Program Supervisor (Civilian) Sworn Officer Civilian Employee Main Contact Email Address(Required) Main Contact Phone Number(Required)Public Safety Agency Name(Required) Agency Mailing Address(Required) Agency Non-Emergency Phone Number(Required)Agency Type Law Enforcement Fire Department University/College Public Safety Recovery Friendly Workplace (Work sites) Emergency Management Agency Service Area City/Municipal County State Federal University/College Tribal Special Jurisdiction (Transit, Hospital, Housing, etc.) Public Safety Agency Website Agency Chief/Executive Officer Name and Title Agency Chief/Executive Officer Phone NumberAgency Chief/Executive Officer Email Address Number of Sworn Officers in Agency (if applicable) 1-10 11-25 26-75 76-150 151-500 501-1000 More than 1000 Number of Civilians in Agency (if applicable) 1-10 11-25 26-75 76-150 151-500 501-1000 More than 1000 Is there anything that makes your community unique? (Fishing, mining, very small or large, etc) Mission Certification(Required)PAARI's mission is to support law enforcement and public safety agencies in designing, launching, and implementing non-arrest addiction referral programs, and to foster a dialogue about the unique position of law enforcement to address the opioid and addiction crisis, remove stigma, and reframe the conversation about addiction as a disease not a crime. PAARI also educates lawmakers and supports policies that increase access to lifesaving resources and treatment. Our goal is to build a law enforcement movement and network of like-minded law enforcement agencies to move away from an arrest-first approach and help people take their first steps on the path to recovery. I have read PAARI's mission above and certify that my agency's mission aligns with PAARI's. My agency would like to join PAARI as a partner. Confirm How did you hear about PAARI? Social Media Referral Google/Other Search Engine Conference or Summit What format of training would you be most likely to attend or use?(Required)1 - Very Unlikely2 - Unlikely3 - Neutral4 - Likely5 - Very LikelyIn-Person Training/ConferencesLive virtual webinarsPre-recorded webinarsRoll call videos (less than 5 minutes)PodcastsNetworking with departments doing similar programsPlease upload your agency's patch.(Required)Max. file size: 50 MB. Program InformationDoes your agency currently have a pre-arrest or other type of program to help individuals with Substance Use Disorder? Yes, we have an active program We are developing a program We previously had a program, but it's now inactive No, but we're interested in more information/researching options PAARI is developing a nationwide map of contacts so that agencies can easily connect with each other. Is it ok to share your contact information with other Public Safety agencies who are partnered with PAARI? Yes No Yes with restrictions and type details in Other What type of program does your agency have or intend to have? Select all that apply. Walk-in/Angel Program/Safe Station: Individuals with substance use disorder voluntarily seek help through department) Officer Referral: Officer/employee encounters an individual with substance use disorder and offers to connect them to treatment) Overdose Outreach: Agency follow up with individuals who have overdosed/at-risk for overdose) Hub model (situation table): Structured collaboration between public safety & community service partners to connect those most at-risk to community resources Officers/employees carry naloxone Law Enforcement Assisted Diversion (LEAD) Emergency Response Teams/Quick Response Team Deflection: Calls deferred at dispatch to social services provider or internal speciality unit Post-arrest/jail diversion related to substance use Other pre-arrest diversion program Date of Program Start (If applicable) MM slash DD slash YYYY Name and Title of Program Supervisor (if different from above)? Is the Program Supervisor a Sworn Officer or Civilian? Sworn Civilian Program Supervisor Phone NumberProgram Supervisor Email Does your agency need resources or assistance in data collection? Yes No Maybe What are you looking for from this partnership with PAARI? Training Resources/connection to other agencies with active programs Program Implementation Educational Materials Other If you selected 'Other' above, elaborate here What format of training would you be most likely to attend or use?1 - Very Unlikely2 - Unlikely3 - Neutral4 - Likely5 - Very LikelyIn-Person Training/ConferencesLive virtual webinarsPre-recorded webinarsRoll call videos (less than 5 minutes)PodcastsUntitled Survey FieldStrongly disagreeDisagreeNeutralAgreeStrongly agree Δ
