Forms
EMS Scope of Practice Special Skills Annual Report Form
EMS Scope of Practice - Form
October 5, 2016
This form should be used for scope of practice special skills annual report renewals.
EMS Scope of Practice Special Skills Report Form
EMS Scope of Practice - Form
October 5, 2016
This form should be used for scope of practice special skills reporting.
EMS Continuing Education Application
EMS Continuing Education - Form
August 15, 2016
This form should be used to notify the emergency medical systems bureau of intent to conduct a continuing education program.
Drug-Facilitated Sexual Assault Toxicology Request Form 2015
Toxicology - Form
July 18, 2016
Use this form to request drug-facilitated sexual assault toxicology analysis.
Syringe Services Daily Log Form
Harm Reduction - Form
June 24, 2016
Use this form to log syringe services.
Arbovirus Case Reporting Form
Zoonotic Diseases - Form
October 14, 2015
Use this form to report cases of West Nile virus to the New Mexico Department of Health.
Immediate Action Safety Plan
Community Programs - Form
September 30, 2015
Develop an Immediate Action Safety Plan to keep people safe and implement the plan when an incident or allegation of abuse, neglect, exploitation, environmental hazard or suspicious injury is reported.
EMD Background Screening Affidavit of No Known Criminal History
EMS Licensing - Form
September 11, 2015
This form is an affidavit of no known criminal history for use by applicants.
Animal Test Request Form
Biology - Form
March 16, 2015
Use this form to request animal specimen analysis.
DDW Case Management: Team Justification Form
Developmental Disabilities Waiver - Form
February 1, 2015
DDW Case Management: Team Justification Form
DDW Case Management: ISP Assessment Tracking Sheet
Developmental Disabilities Waiver - Form
February 1, 2015
DDW Case Management: ISP Assessment Tracking Sheet
Report of Audiological Results Form
Children's Medical Services - Form
December 9, 2014
This form is used by audiologists to report their audiological results to the New Mexico Department of Health after screening a newborn’s hearing.
EMS Trauma Hospital Reporting Form
EMS Trauma Care Program - Form
October 1, 2014
This form should be used by emergency medical services hospitals to report community outreach and prevention activities.
EMS Cardiac Arrest Response AED Program Registration Packet
EMS Targeted Cardiac Response Program - Form
September 5, 2014
This packet should be used by any person or entity operating or creating an automated external defibrillator program within the state of New Mexico. This packet also contains several other items including a notification of program form, usage data collection form, and a checklist of guidelines for establishing a program.
Substitute W-9 Form
Public Relations - Form
August 27, 2014
This form should be used to provide a substitute W-9 form to the New Mexico department of finance and administration's financial control division.
VFC Transport Temperature Log Form for Frozen Vaccines
Immunization - Form
June 27, 2014
Complete this log when transporting vaccines to an alternate or back-up freezer.
Primary Care Capital Fund Application
Primary Care & Rural Health - Form
May 13, 2014
Primary and capital fund application for financial assistance to the New Mexico Department of Health and New Mexico finance authority.
EMS Do Not Resuscitate Order Form
EMS Advance Directives - Form
April 30, 2014
This form is to place a formal Do Not Resuscitate order. For covered persons in cardiac or respiratory arrest, resuscitative measures to be withheld include external chest compressions, intubation, defibrillation, administration of cardiac medications and artificial respiration.