Forms
CDC-Revised document as COVID-19 Vaccine Program Provider Agreement
Immunization - Form
May 18, 2022
CDC-Revised document as COVID-19 Vaccine Program Provider Agreement
CDC-Supplemental document as COVID-19 Vaccine Redistribution Agreement
Immunization - Form
May 18, 2022
CDC-Supplemental document as COVID-19 Vaccine Redistribution Agreement
NMSIIS User Security and Confidentiality Agreement
Immunization - Form
January 26, 2022
User security and confidentiality agreement for the New Mexico Statewide Immunization Information System.
NMSIIS Participant Organization Security and Confidentiality Agreement
Immunization - Form
January 1, 2022
Participant organization security and confidentiality agreement for the New Mexico Statewide Immunization Information System.
NMSIIS Decision to Remove Record
Immunization - Form
December 30, 2021
This form is used by a patient/parent/legal guardian to remove records from the New Mexico Statewide Immunization Information System.
NMSIIS Decline to Participate Form
Immunization - Form
December 30, 2021
This form is used by a patient/parent/legal guardian to decline to participate in the New Mexico Statewide Immunization Information System.
VFC Vaccine Administration Form (Part B)
Immunization - Form
October 1, 2021
This form allows you to provide immunization information for entry into NMSIIS.
Adult Vaccine Consent Form
Immunization - Form
October 1, 2021
This form may be used by adult patients aged 19 and older to provide vaccination consent to a healthcare provider.
Got Shots Fillable Form
Immunization - Form
July 1, 2021
Got Shots Fillable Form
Got Shots? Fillable Form - Eng
Got Shots? Fillable Form - Esp
COVID-19 Vaccine Consent Form English
Immunization - Form
March 25, 2021
This form should be used as Consent for COVID-19 Vaccinations
COVID-19 Vaccine Consent Form Spanish.
Immunization - Form
February 25, 2021
This form should be used as Consent for COVID-19 Vaccinations
COVID-19 Vaccine Consent Form Spanish
Immunization - Form
December 18, 2020
This form should be used as Consent for COVID-19 Vaccinations
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.
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
VFC Northwest Region Temperature Log Form
Immunization - Form
June 29, 2020
Cibola, McKinley, San Juan, Sandoval, Torrance, and Valencia