NM BON Diversion ProgramResponse Checklist

NM BON Diversion Program Response Checklist

6301 Indian School RD NE Ste 701 Albuquerque, NM 87110 Office: 505.841.9091 Email : nmbon.diversion@bon.nm.gov
Response Checklist

Submit a Response within 20 days of receipt of a DP offer following a complaint
Name*

First NameLast Name
License number*
Type of License(s)*
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Cell Phone Number*
Please enter a valid phone number.
Home Phone Number
Please enter a valid phone number.
Email*
example@example.com
REQUIRED: Please Answer the Following Questions
I admit that I have a substance use disorder and/or that I have a problem with drugs, prescription medications, and/or alcohol use or abuse*

YesNo
I am voluntarily requesting admission into the Diversion Program for nurses with substance use disorders and agree to complete my admission within two weeks*

YesNo
I understand I need to enter into a minimum level of care intensive outpatient treatment or inpatient treatment for substance use disorder within the next two weeks*

YesNo
I acknowledge and understand the requirements of the NM Board of Nursing Diversion Program.*

YesNo
I have checked No to the questions above and do not request admission into the NM Board of Nursing Diversion Program. I have included my response below to the complaint and have signed and dated this response form.*

Acknowleged
I am voluntarily requesting admission into the NM Board of Nursing Diversion Program, and I have checked Yes to the questions above. I will submit my written request below to include a brief history of my substance use disorder and reason for my request. I have signed and dated this response.*

Acknowledged
How were you referred to the NM Board of Nursing Diversion Program*

Self ReferralComplaintBoard Referral
Response to the NM Board of Nursing Diversion Program (please tell us why you are entering the DP)
Any additional Comments
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 legal binding electronic signature for this document.
Signature*

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NM BON Diversion Program Response Checklist

Response Checklist

REQUIRED: Please Answer the Following Questions