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Forms


Photo of the publication cover. COVID-19 Vaccine Consent Form English Immunization - Form March 25, 2021

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



Photo of the publication cover. COVID-19 Vaccine Consent Form Spanish. Immunization - Form February 25, 2021

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



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. 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. School Consent to Enter Student Records into NMSIIS Immunization - Form September 17, 2018

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



Photo of the publication cover. VFC Approved School Sites - Needle, Syringe, & e-kit Order Form Immunization - Form February 23, 2018

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



Photo of the publication cover. VFC Middle School Vaccination Letter/Permission Form Immunization - Form February 23, 2018

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)



Photo of the publication cover. VFC Program Data Logger Timeline and Checklist Immunization - Form January 26, 2018

This document is for providers: guidelines and important dates for the transition to digital data loggers.



Photo of the publication cover. Adult Vaccine Order Form Immunization - Form October 10, 2017

Healthcare providers may use this form to order adult vaccines.

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