Hemodialysis Technician Nurse Educator Request

Hemodialysis Technician Program Nurse Educator

Notification of change and 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.*
File Upload

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Program location address*

Address

Address Line 2

CityState

Zip Code
Name of current or most recent nurse educator*

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

MonthDayYear
Date
Please provide 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)*
Name of proposed nurse educator*

First NameLast Name
Proposed date of appointment*

MonthDayYear
Date
Mailing address of proposed nurse educator*

Street Address

Street Address Line 2

CityState

Postal / Zip Code
Contact telephone number of proposed nurse educator*
Please enter a valid phone number.
Email address of proposed nurse educator*
example@example.com
Is the proposed nurse educator a registered nurse and hold a current license to practice nursing in NM or a current compact state license (Paragraph (1) of Subsection D of 16.12.4.14 NMAC)? If Yes, upload licensure verification.
Upload licensure verification.*

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Does the proposed nurse educator have at least two years of recent nursing practice experience including at least one year of nursing experience in hemodialysis (Paragraph (2) of Subsection D of 16.12.4.14 NMAC)? If Yes, upload current resume.
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Does the proposed nurse educator have a minimum of nine contact hours of continuing education annually in nephrology or have current national certification in nephrology or dialysis (Paragraph (3) of Subsection D of 16.12.4.14 NMAC)? If Yes, 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
File Upload

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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