Forms

VFC Metro Region Temperature Log Form Immunization - Form November 14, 2024

County: Bernalillo

VFC Northeast Region Temperature Log Form Immunization - Form November 14, 2024

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

VFC Northwest Region Temperature Log Form Immunization - Form November 14, 2024

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

VFC Southeast (A) Region Temperature Log Form Immunization - Form November 14, 2024

Chaves, Curry, DeBaca, Lincoln, and Quay

VFC Southeast (B) Region Temperature Log Form Immunization - Form November 14, 2024

Eddy, Lea, Lincoln, and Roosevelt

VFC Southwest Region Temperature Log Form Immunization - Form November 14, 2024

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

VFC Transport Temperature Log Form for Refrigerated Vaccines Immunization - Form September 26, 2024

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

NMSIIS Decision to Remove Record Immunization - Form June 14, 2024

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

NMSIIS Decision to Remove Record (Spanish)

NMSIIS Organization Security and Confidentiality Agreement 2024 Immunization - Form June 5, 2024

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

NMSIIS User Security and Confidentiality Agreement 2024 Immunization - Form June 5, 2024

NMSIIS User Security and Confidentiality Agreement 2024

Certificate of Exemption from Immunization (English) Immunization - Form June 5, 2024

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

Certificate of Exemption from Immunization (Spanish) Immunization - Form June 5, 2024

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.

NMSIIS Decline to Participate Form Immunization - Form June 3, 2024

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

NMSIIS Decline to Participate (Spanish)

VFC Routine Vaccine Management Plan Immunization - Form October 23, 2023

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.

VFC Emergency Vaccine Management Plan Immunization - Form October 23, 2023

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.