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Forms


Photo of the publication cover. EMS Re-Entry Licensing Application EMS Licensing - Form August 15, 2017

This form should be used for re-entry applicants.

Re-Entry Licensing Instructions



Photo of the publication cover. Overdose Prevention and Education and Syringe Service Program Registration Form Harm Reduction - Form July 26, 2017

Use this form to register for the overdose prevention and education and syringe exchange program.



Photo of the publication cover. JOE Instructor Coordinator Renewal Application EMS Committees - Form July 14, 2017

This is the renewal application for existing instructor/coordinators.



Photo of the publication cover. JOE Instructor Coordinator Initial Application EMS Committees - Form July 14, 2017

This is the initial application for new instructor/coordinators.



Photo of the publication cover. JOE Instructor Coordinator Re-Entry Application EMS Committees - Form July 14, 2017

This is the re-entry application for instructor/coordinators.



Photo of the publication cover. Harm Reduction and Hepatitis Monthly Report Cover Sheet Harm Reduction - Form July 5, 2017

This is the monthly report cover sheet for the harm reduction and hepatitis program.



Photo of the publication cover. Naloxone Inventory and Order Form Harm Reduction - Form July 5, 2017

Use this form to manage inventory and orders of naloxone.



Photo of the publication cover. Naloxone Enrollment and Record of Use Form Harm Reduction - Form July 5, 2017

Use this form to enroll and record use of naloxone.



Photo of the publication cover. Syringe Service Enrollment and Daily Log Form Combined Harm Reduction - Form July 5, 2017

Combined syringe service enrollment and daily log forms.



Photo of the publication cover. DDW Living Support: Staffing Grid for Supported Living Tiered Rates Developmental Disabilities Waiver - Form July 1, 2017

DDW Living Support: Staffing Grid for Supported Living Tiered Rates



Photo of the publication cover. Community Health Worker Continuing Education Unit Provider Application Community Health Workers - Form June 8, 2017

This is the application to become an approved Continuing Education Unit Provider.



Photo of the publication cover. JOE Education Designee Form EMS Committees - Form May 19, 2017

This form is applicable for the following entities to utilize: the director and medical director of the academy, and the director and medical director of each approved emergency medical services training program, the state emergency medical services medical director, and the bureau chief whose designee shall serve without vote.



Photo of the publication cover. JOE Proxy Form EMS Committees - Form May 19, 2017

This form is applicable for the following entities to utilize: Each emergency medical services regional office training coordinator and providers from the three highest levels of licensure, who are appointed by the secretary from a list proposed by the statewide EMS advisory committee.



Photo of the publication cover. VFC Vaccine Return Form Immunization - Form April 21, 2017

This form is used to return vaccines and to track your inventory. Vaccines that are returned are then cleared from your inventory. Complete and fax this form to the NM VFC Program before you return any vaccines.



Photo of the publication cover. Family Planning Sterilization Provider Evaluation Form Family Planning - Form April 11, 2017

Use this form to evaluate a steralization provider.



Photo of the publication cover. Notifiable Condition Reporting Form Infectious Disease Epidemiology - Form April 4, 2017

Use this form to report notifiable conditions to the department of health.



Photo of the publication cover. Syringe Services Interview Form Harm Reduction - Form January 31, 2017

Use this form for syringe services interviews.



Photo of the publication cover. Naloxone Medication Log for Secure Designated Storage Location – Sample Harm Reduction - Form January 19, 2017

This an example of how to complete the log (required by regulation) tracking naloxone medication.



Photo of the publication cover. Naloxone Medication Log for Secure Designated Storage Location Harm Reduction - Form January 19, 2017

This is a log (required by regulation) tracking naloxone medication.



Photo of the publication cover. Medicaid Application Allocation Process - Form January 1, 2017

Medicaid Application

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