Forms
EMS Re-Entry Licensing Application
EMS Licensing - Form
August 15, 2017
This form should be used for re-entry applicants.
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.
JOE Instructor Coordinator Renewal Application
EMS Committees - Form
July 14, 2017
This is the renewal application for existing instructor/coordinators.
JOE Instructor Coordinator Initial Application
EMS Committees - Form
July 14, 2017
This is the initial application for new instructor/coordinators.
JOE Instructor Coordinator Re-Entry Application
EMS Committees - Form
July 14, 2017
This is the re-entry application for instructor/coordinators.
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.
Naloxone Inventory and Order Form
Harm Reduction - Form
July 5, 2017
Use this form to manage inventory and orders of naloxone.
Naloxone Enrollment and Record of Use Form
Harm Reduction - Form
July 5, 2017
Use this form to enroll and record use of naloxone.
Syringe Service Enrollment and Daily Log Form Combined
Harm Reduction - Form
July 5, 2017
Combined syringe service enrollment and daily log forms.
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
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.
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.
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.
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.
Family Planning Sterilization Provider Evaluation Form
Family Planning - Form
April 11, 2017
Use this form to evaluate a steralization provider.
Notifiable Condition Reporting Form
Infectious Disease Epidemiology - Form
April 4, 2017
Use this form to report notifiable conditions to the department of health.
Syringe Services Interview Form
Harm Reduction - Form
January 31, 2017
Use this form for syringe services interviews.
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.
Naloxone Medication Log for Secure Designated Storage Location
Harm Reduction - Form
January 19, 2017
This is a log (required by regulation) tracking naloxone medication.
