Forms

VaxViewNM Demographic and Contact Information Form

This form is used by a patient/parent/legal guardian to remove records from the New Mexico Statewide Immunization Information System.

This form is used by a patient/parent/legal guardian to decline to participate in the New Mexico Statewide Immunization Information System.

This form may be used by individuals requesting a religious or medical exemption to immunization for their children whom attend any public, private or parochial pre-school, kindergarten, elementary, secondary school, or home school and for children attending daycare of childcare facilities.

Certificate of Exemption FAQ

This form may be used by individuals requesting a religious or medical exemption to immunization for their children whom attend any public, private or parochial pre-school, kindergarten, elementary, secondary school, or home school and for children attending daycare of childcare facilities.

User security and confidentiality agreement for the New Mexico Statewide Immunization Information System.

Participant organization security and confidentiality agreement for the New Mexico Statewide Immunization Information System.

Complete this log when transporting vaccines to an alternate or back-up refrigerator, or when transferring to another provider.

Cibola, McKinley, San Juan, Sandoval, Torrance, and Valencia

The New Mexico VFC Program requires each practice to develop and maintain an Emergency Vaccine Management Plan. Properly completing this template will meet the VFC Program requirement to have a written plan for storage and handling procedures in an emergency.

The New Mexico VFC Program requires each practice to develop and maintain a Routine Vaccine Management Plan. Properly completing this template will meet the VFC Program requirement for VFC Program participants to have written vaccine storage and handling plans.

This form should be used to report out of range temperature incidents and submit a troubleshooting record to the vaccines for children program.

This form may be used by adult patients aged 19 and older to provide vaccination consent to a healthcare provider.

Adultos Vacuna Formulario de Consentimiento

This form allows you to provide immunization information for entry into NMSIIS.

VFC Vacuna Forma Administración (Parte B)

This is the form to be completed by parents or guardians indicating whether or not a child is to be vaccinated at school.

VFC School Immunization Consent Form (Spanish)

This is a customizable form for use by schools to collect consent from parents so students' historic immunization records may be added to NMSIIS.

Borrowing vaccines between VFC and State inventories can only take place due to unforeseen delays or circumstances surrounding the vaccines that were ordered. The provider must assure that borrowing VFC vaccines will not prevent a VFC eligible child from receiving a needed vaccination because VFC vaccine was administered to a non-VFC eligible (State) child.

All VFC providers are required to submit this annual VFC certification form in order to continue receiving VFC vaccines.

VFC Instructions on Digital Signature and Attaching License

This form is to be used for needles/syringes, and e-kit medications and is for Vaccines for Children Approved Sites Only.

This is the letter addressed to parents or legal guardians to determine whether or not a child is to be vaccinated at school. This letter is to be sent out with the VFC school immunization consent form.

VFC Middle School Vaccination Letter/Permission Form (Spanish)