Lower East Side Harm Reduction Center
{PDSEP}
Participants Enrollment Form
I - General Information:
Date: ______Zip: ______
Ethnicity (check one) [ ] Non-Hispanic [ ] Hispanic / specific [ ] Dominican [ ] Puerto Rican
[ ] South American [ ] Mexican/Mexican-American [ ] Chicano or [ ] Other
Race (check one) [ ] African American/ Black [ ] White/Caucasian [ ] Asian/Pacific Islander
[ ] Native American [ ] Other______
Gender (check one) [ ] Male [ ] Female [ ] Transgender [Male or Female]
How do you use? [ ] intravenous [ ] snort [ ] skin pop [ ] other______How long? ______
II- Syringe Exchange ID Code:
How to make an ID code:
1. First two letter of the participant last name, ______
2. First letter of participant mothers first name, ______
3. The day of participant birth, ______
4. Then add a (P) so we know its PDSP. (X, Y, Z, or W) if code has been already given out.
5. However you must obtain the complete date of birth in order to enroll participants into the syringe exchange program.
6. Date of birth, ______
7. Participants ID Code (______)
III- Services Questions:
Would you be interested in the following?
1. Taking a HIV test? [ ] Yes [ ] No
2. Hepatitis testing, vaccination, or treatment? [ ] Yes [ ] No
3. TB testing or treatment? [ ] Yes [ ] No
4. Substance use treatment? [ ] Yes [ ] No
5. Are you currently housed? [ ] Yes [ ] No
Recorder (Print Name Clearly): ______
#Of Syringe In: Out: / Entered into AIRS by:Lower East Side Harm Reduction Center
Syringe Exchange safer injection and disposal information
Safe Injection
The “Golden Rule” of safer injection is to use a sterile syringe every time you inject (this also goes for cookers, cotton, water, and ties-use new equipment every time). If a sterile syringe is not available, you need to clean a used on with bleach before you use it.
How to bleach a set:
Rinse 3 times with clean, cold water (hot water can cause the blood to clot, making the syringe difficult to clean). Shake or tap syringe to try to remove as much blood as possible-it only takes a little bit to contaminate the syringe.
Rinse 2 times with bleach. Leave bleach in syringe at least 30 seconds each time.
Rinse 3 times with clean, cold water.
Cleaning syringe with bleach will reduce the chances of spreading HIV and Hepatitis C, but it is not as safe as using a sterile syringe.
Before you inject
Wash your hands with soap and water
Find a clean, level surface to prepare your shot (Hepatitis C lives outside the body-it can hang out on surface areas for more than four days). Spray contents from syringe away from where you are setting up your shot.
Use alcohol pad to avoid pushing bacteria into the bloodstream. Wipe once in a single direction; do not use circular motion; it is best to let alcohol dry for 30 seconds to make sure the alcohol kills as much bacteria as it can before injection. Do not use alcohol pad after injection; blood will not clot.
Inject towards the heart. 15 degrees for IV, 15 degrees to 45 degrees for skin pop and 90 degrees for muscle.
Good spots are arms and legs. Less ideal spots are hands, legs, feet, groin, neck; veins here have thin walls, slow circulation, or are dangerously close to nerves.
If you miss a shot, return it to the cooker, add water, do not reheat, try again with a new or clean syringe. Try to relax before you hit again.
Overdose prevention
Know your tolerance (it can decrease after only three days of not using); know your supply; be aware of mixing; don’t slam your shot (once it’s in, you can’t get it out); try not to use alone.
Are you interested in receiving Naloxone? (Provide Naloxone training information and schedule)
Safe syringe Disposal
Dispose your used syringes here at the exchange, safely and easily. We provide sharp containers. If you don’t want to dispose here, put used syringes in plastic bottle, label “medical waste,” and throw away as normal trash. Do not flush syringes down toilet. If you must break the tip, store it inside plunger.
Syringe Exchange Operation
Know your rights
Registered with us, you can legally obtain and possess syringes (in NYC and NY State)-with card it is now legal to carry used syringes back to agency for exchange; best to have ID card on you at all times to minimize harassment. Let us know if you are arrested.
You can also buy syringes in pharmacies under ESAP; keep receipt and safety insert as proof of purchase.
Syringe Exchange Policy
With exchange
1 for 1 plus 10 up to 50
After 50, 1 for 1. Cap at 250 Without Exchange
Without ID, if 20 syringes is not enough can get up to 30 syringes at staff discretion.
Agency Rules
No violence, drug dealing, threats to staff, using on premises (i.e. hanging out or smoking) in front of the agency. Failure to adhere to agency rules can result in suspension of services.