Forms
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.
Credentialing COVID-19 Providers Form
2019 Novel Coronavirus - Form
December 10, 2020
Credentialing COVID-19 Providers Form
EMS Local Funding Program Application Form FY22
EMS Fund Act - Form
November 6, 2020
EMS Local Funding Program Application Form
EMS Local Funding Program Annual Service Report Form FY22
EMS Fund Act - Form
November 6, 2020
EMS Local Funding Program Annual Service Report Form
EMS TSFA Trauma System Development Application FY22
EMS Committees - Form
October 13, 2020
This document describes the required process for eligible trauma system development projects to receive funding. Funding will be issued through a separate agreement between each approved organization and the New Mexico Department of Health Memorandum of Agreement process.
COVID Test Request Form
Scientific Laboratory - Form
October 9, 2020
COVID Test Request Form Prefilled
Naloxone Standing Order Prescription Hardcopy
Opioid Safety - Form
July 8, 2020
This is the document used to order Naloxone HCI Solution, Narcan Nasal Spray, or Evzio.
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
VFC Northwest Region Temperature Log Form
Immunization - Form
June 29, 2020
Cibola, McKinley, San Juan, Sandoval, Torrance, and Valencia
VFC Southeast (A) Region Temperature Log Form
Immunization - Form
June 29, 2020
Chaves, Curry, DeBaca, Lincoln, and Quay
Breath Alcohol Instrument Peripheral Ordering
Breath Alcohol - Form
May 29, 2020
Breath Alcohol Instrument Peripheral Ordering
Public Health Emergency Licensing Instruction
EMS Licensing - Form
April 7, 2020
Public Health Emergency Licensing Instruction
Still Birth Record Search Application
Vital Records - Form
February 26, 2020
Use this form to request a still birth certificate.
Water Analysis Request Form
Biology - Form
February 19, 2020
Use this form to request water sample analysis.
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.
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.
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.
Request to Change Gender Designation on a Birth Certificate: Adult Form
Vital Records - Form
October 28, 2019
This form allows an adult to request a gender designation change on their own birth certificate.
Request to Change Gender Designation on a Birth Certificate: Parent/Legal Guardian Form
Vital Records - Form
October 28, 2019
This form allows the legal parent/guardian to request a gender designation change on their child's birth certificate.
Request to Change Gender Designation on a Birth Certificate: Two Parent Signature Form
Vital Records - Form
October 28, 2019
This form allows parents to request a gender designation change on their child's birth certificate.