Hemodialysis Technician Nurse Educator Request

Hemodialysis Technician Program Nurse Educator

Notification of Change & Request for Approval
Notification of change must be submitted by a program administrator (Paragraph (1) of Subsection A of 16.12.4.7 NMAC).
Name of Board-approved hemodialysis technician program/facility. For multiple programs, please upload a list.*
Program location address*

Address

Address Line 2

CityState

Zip Code
Are you submitting a request for a single nurse educator for multiple facilities?

YesNo
Please Upload New Organizational Chart

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Name of current or most recent nurse educator*

First NameLast Name
End date of current or most recent nurse educator appointment*

MonthDayYear
Date
Name of proposed nurse educator*

First NameLast Name
Telephone number of proposed nurse educator*
Please enter a valid phone number.
Email address of proposed nurse educator*
example@example.com
Proposed date of appointment*

MonthDayYear
Date
What is the rationale for the proposed change (see 16.12.4.13 NMAC)*
What is the anticipated effect of the change on the current program (see 16.12.4.13 NMAC)*
"The nurse educator shall be a registered nurse and shall hold a current New Mexico or multistate license to practice nursing in New Mexico or hold a current compact license." (Paragraph (1) of Subsection D of 16.12.4.14 NMAC)
Upload licensure verification.*

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"The nurse educator shall have at least two years of recent nursing experience including at least one year of nursing experience in hemodialysis." (Paragraph (2) of Subsection D of 16.12.4.14 NMAC)
Upload resume including current position*

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"The nurse educator shall have a minimum of nine contact hours of continuing education annually in nephrology, or have a national certification in nephrology or dialysis." (Paragraph (3) of Subsection D of 16.12.4.14 NMAC)?
Upload verifying documentation*

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Has the proposed nurse educator previously attended a BON nurse educator orientation as required by hemodialysis technician rules (Paragraph (4) of Subsection D of 16.12.4.12 NMAC)?*

No. Nurse educators who have not already attended an orientation may register on the hemodialysis technician program page.Yes. Please upload certificate or verification of attendance
Verification of attendance of Nurse Educator Orientation

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Completed by (Administrator name)*

First NameLast Name
Title*
Administrator's mailing address*
Administrator's telephone number*
Please enter a valid phone number.
Administrator's 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.
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Hemodialysis Technician Program Nurse Educator