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Photo of the publication cover. NMSIIS User Security and Confidentiality Agreement Immunization - Form January 4, 2021

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



Photo of the publication cover. NMSIIS Participant Organization Security and Confidentiality Agreement Immunization - Form January 4, 2021

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



Photo of the publication cover. NMSIIS Decision to Remove Record Immunization - Form January 4, 2021

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



Photo of the publication cover. NMSIIS Decline to Participate Form Immunization - Form January 4, 2021

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



Photo of the publication cover. COVID-19 Vaccine Consent Form Spanish Immunization - Form December 18, 2020

This form should be used as Consent for COVID-19 Vaccinations



Photo of the publication cover. VFC COVID-19 Troubleshooting Record Form Immunization - Form December 15, 2020

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



Photo of the publication cover. VFC Metro Region Temperature Log Form Immunization - Form June 29, 2020

County: Bernalillo



Photo of the publication cover. VFC Northeast Region Temperature Log Form Immunization - Form June 29, 2020

Colfax, Guadalupe, Harding, Los Alamos, Mora, Rio Arriba, San Miguel, Santa Fe, Taos, and Union



Photo of the publication cover. VFC Northwest Region Temperature Log Form Immunization - Form June 29, 2020

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



Photo of the publication cover. VFC Southeast (A) Region Temperature Log Form Immunization - Form June 29, 2020

Chaves, Curry, DeBaca, Lincoln, and Quay



Photo of the publication cover. VFC Southeast (B) Region Temperature Log Form Immunization - Form June 29, 2020

Eddy, Lea, Lincoln, and Roosevelt



Photo of the publication cover. VFC Southwest Region Temperature Log Form Immunization - Form June 29, 2020

Catron, Dona Ana, Grant, Hidalgo, Luna, Otero, Sierra, and Socorro



Photo of the publication cover. VaxViewNM Demographic and Contact Information Form Immunization - Form April 15, 2020

VaxViewNM Demographic and Contact Information Form



Photo of the publication cover. Certificate of Exemption from Immunization (English) Immunization - Form April 14, 2020

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



Photo of the publication cover. Certificate of Exemption from Immunization (Spanish) Immunization - Form April 14, 2020

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.



Photo of the publication cover. VFC Transport Temperature Log Form for Refrigerated Vaccines Immunization - Form February 14, 2020

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



Photo of the publication cover. VFC Emergency Vaccine Management Plan Immunization - Form November 22, 2019

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.



Photo of the publication cover. VFC Routine Vaccine Management Plan Immunization - Form November 22, 2019

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.



Photo of the publication cover. Adult Vaccine Consent Form Immunization - Form September 9, 2019

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



Photo of the publication cover. VFC Vaccine Administration Form (Part B) Immunization - Form September 9, 2019

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

VFC Vacuna Forma Administración (Parte B)

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