Safe Disposal Support Program Application

PROGRAM OVERVIEW & DETAILS

The AmerisourceBergen Foundation thanks you for your interest and commitment to combating the epidemic of opioid misuse.

OVERVIEW: This program provides organizations with access to drug deactivation pouch or packet resources that enable community members to dispose of unused or expired prescription drugs in a safe and effective manner. The deactivation resources allow for local, on-site disposal and can be distributed to other organizations, individuals or households. Applications will be accepted until September 30, 2018. More information about the program can be found here.

Examples of the drug deactivation resources that this program provides, includes, but is not limited to, products such as those manufactured by DisposeRx and Deterra Drug Deactivation System.

ELIGIBILITY: U.S. government (city, county or state) or IRS-registered 501(c)3 nonprofit organizations, or a joint application of both types of organizations or community-based coalitions, are eligible to apply. Previous, current or prospective customers of AmerisourceBergen Corporation (or any of its companies) are not eligible to receive resources, due to the bylaws of AmerisourceBergen Foundation. The only possible exception is a collaborative partnership with a nonprofit or municipal outreach project that has a demonstrated public benefit, as these resources are not intended for customers’ patient populations or for pharmacy disbursement.

DISTRIBUTION: Drug deactivation resources will be distributed utilizing AmerisourceBergen Corporation's network of U.S. distribution centers. Logistics will be determined based on the location of the organization requesting the resources, as well as the requested quantity. Once received from the AmerisourceBergen Foundation, organizations will have the discretion to determine how to distribute the resources to achieve the most efficient and effective application. Note that these resources cannot be distributed from a pharmacy.

Recipient organizations are encouraged to work with other partner organizations to determine the distribution process, based on local community needs.

HOW TO APPLY: If your municipality or nonprofit organization is interested in receiving drug deactivation pouch or packet resources, please fill out the application below. The AmerisourceBergen Foundation will respond within 10 business days. While our goal is to distribute the resources, factors may prohibit us from granting all requests. Questions on the application can be sent via email to ABCFoundation@amerisourcebergen.com.

Organization Information

Question Title

1. Organization Information

Name of Nonprofit Organization or Municipality

Street Address

City, State and Zip

Phone

Website

Category of Organization

Question Title

2. Category of Organization

Nonprofit

Municipality

A joint application by a Nonprofit and Municipality

Primary Contact Information

Question Title

3. Primary Contact Information

Name

Title

Phone

Shipping Information (if approved, where resources would be sent to, if different than the Organization Information above)

Question Title

4. Shipping Information (if approved, where resources would be sent to, if different than the Organization Information above)

Same as above? (Yes or if No, complete boxes below)

Name of Nonprofit Organization or Municipality

Name of Primary Contact Person

Street Address

City, State and Zip

Phone

A. State the mission of your organization, and B. Summarize how it aligns with the work being done to combat the opioid crisis.

Question Title

5. A. State the mission of your organization, and B. Summarize how it aligns with the work being done to combat the opioid crisis.

Has your organization/municipality already been involved in work to combat the opioid crisis, either internally, as services to others, or in partnership with other organizations?

Question Title

6. Has your organization/municipality already been involved in work to combat the opioid crisis, either internally, as services to others, or in partnership with other organizations?

Yes

If yes, please summarize your work, programs and timing in regards to the opioid crisis:

Please detail how you plan to utilize and/or distribute the drug deactivation resources in your community. Please be as specific as possible.

Question Title

7. Please detail how you plan to utilize and/or distribute the drug deactivation resources in your community. Please be as specific as possible.

Total amount of drug deactivation resources requested (Note: resources provide safe, on-site disposal and can distributed to individuals or households)

Question Title

8. Total amount of drug deactivation resources requested (Note: resources provide safe, on-site disposal and can distributed to individuals or households)

200

400

1000

2000

Other (please specify)

Projected duration of utilization/distribution of drug deactivation resources (how long you think they will last):

Question Title

9. Projected duration of utilization/distribution of drug deactivation resources (how long you think they will last):

Given geographical considerations, might there be an opportunity for AmerisourceBergen associates to participate in or volunteer at an event?

Question Title

10. Given geographical considerations, might there be an opportunity for AmerisourceBergen associates to participate in or volunteer at an event?

Yes

What is your role in this request?

Question Title

11. What is your role in this request?

I work/volunteer for the non-profit organization or municipality/local officials that will receive the destruction pouches

I am a contract fundraiser

Other (please describe)

Select all that apply. Your organization:

Question Title

12. Select all that apply. Your organization:

Has worked with an AmerisourceBergen Corporation business entity in the past

Is currently a customer of an AmerisourceBergen Corporation business entity

Is currently engaged in discussions regarding the purchase of products or services from an AmerisourceBergen business entity

None of the above (our organization has no business relationship with AmerisourceBergen Corporation)

We would like to raise awareness about the availability of these resources. (Select all that apply) Can you assist in this effort by:

Question Title

13. We would like to raise awareness about the availability of these resources. (Select all that apply) Can you assist in this effort by:

Recognizing this donation from the AmerisourceBergen Foundation via our own resources

Being willing to participate in media relations efforts (i.e. press release) regarding this donation

Sorry, we will be unable to spread the word about this donation.

If so, please describe how:

Please provide any comments or questions, about the products or the program, that were not addressed in the information and links provided in the introduction above?

Question Title

14. Please provide any comments or questions, about the products or the program, that were not addressed in the information and links provided in the introduction above?

REQUIRED LAST STEP:
Please complete one last step to finalize your application, by returning a signed Donation Agreement form. Instructions:
1. Click on this link to a Donation Agreement form (or copy and paste this URL https://amerisourcebergen-public.box.com/v/ABCFoundationDonationsForm into your browser).
2. The link will take you to a new window, which has a document linked to it. Select "Download" to save the form to your computer.
3. Print, complete and sign the form.
4. Scan the signed form into your computer and save it as a file.
5. Return back to this application tool/link and scroll to this last question.
6. See the section, and click on, "Choose File." Select the signed form from the files/documents on your computer, to Upload the Donation Agreement form document.
7. Once uploaded, select the "Submit" button at the bottom of this application page, to complete your application.

Question Title

15. REQUIRED LAST STEP:
Please complete one last step to finalize your application, by returning a signed Donation Agreement form. Instructions:
1. Click on this link to a Donation Agreement form (or copy and paste this URL https://amerisourcebergen-public.box.com/v/ABCFoundationDonationsForm into your browser).
2. The link will take you to a new window, which has a document linked to it. Select "Download" to save the form to your computer.
3. Print, complete and sign the form.
4. Scan the signed form into your computer and save it as a file.
5. Return back to this application tool/link and scroll to this last question.
6. See the section, and click on, "Choose File." Select the signed form from the files/documents on your computer, to Upload the Donation Agreement form document.
7. Once uploaded, select the "Submit" button at the bottom of this application page, to complete your application.

If you have issues with this process, you can alternatively scan the Donation Agreement form, and email the signed form to abcfoundation@amerisourcebergen.com.

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