Medication Aide Program Nurse Educator Request

Medication Aide Program Nurse Educator

Notification of Change & Request for Approval
Notification of change must be submitted by agency administrator in accordance with medication aide rules (Paragraph (4) of Subsection C of 16.12.5.17 NMAC).
Name of Board-approved medication aide program/facility
Program address

Address

Address Line 2

CityState

Postal / Zip Code
Name of current or most recent nurse educator

First NameLast Name
End date of current nurse educator appointment

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Name of proposed nurse educator

First NameLast Name
Telephone number of proposed nurse educator
Please enter a valid phone number.Format: (000) 000-0000.
Email address of proposed nurse educator
example@example.com
Proposed date of appointment

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
What is the rationale for the proposed change (see 16.12.5.16 NMAC)?
What is the anticipated effect of the change on the current program (see 16.12.5.16 NMAC)? Note: please do not enter a date.
“Each program shall have a nurse educator that is a registered nurse and holds a current license to practice nursing in NM or a current compact state license.” (Paragraph (1) of Subsection D of 16.12.5.17 NMAC).
Upload licensure verification

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Each medication aide program must have a nurse educator who holds a current New Mexico or multistate nursing license and has at least two years of nursing practice experience within the preceding five years [16.12.5.17(D)(1)–(2) NMAC].
Upload resume including current position

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Has the proposed nurse educator previously attended a BON nurse educator orientation as required by Medication Aide Rules (Subsection B of 16.12.5.12 NMAC)?
Verification of attendance of Nurse Educator Orientation

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AFFIRMATION AND SIGNATURE

I affirm the following: I am authorized to make this request; the information provided is true and correct; I have verified that the proposed nurse educator meets requirements; and I understand that medication aide rules require agency administration shall provide support for the medication aide program to obtain the resources needed for the program to achieve its purpose (16.12.5.17 NMAC).
Completed by (Administrator name)

First NameLast Name
Title
Administrator phone number
Please enter a valid phone number.Format: (000) 000-0000.
Administrator email address
example@example.com
By digitally signing below, I attest that all the information provided in this webform is true, accurate, and complete to the best of my knowledge. I understand that any false or misleading information may result in consequences as determined by applicable laws and regulations. I acknowledge that the digital signature is my legally binding electronic signature for this document.
Signature
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