NM BON Alternative to Discipline Program Response Checklist

NM BON Alternative to Discipline Program Response Checklist

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

Submit a Response within 20 days of receipt of Alternative to Discipline 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.Format: (000) 000-0000.
Home Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
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
I am voluntarily requesting admission into the Alternative to Discipline Program for nurses with substance use disorders and agree to complete my admission within two weeks
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
I acknowledge and understand the requirements of the NM Board of Nursing Alternative to Discipline Program.
I have checked No to the questions above and do not request admission into the NM Board of Nursing Alternative to Discipline Program. I have included my response below to the complaint and have signed and dated this response form.
I am voluntarily requesting admission into the NM Board of Nursing Alternative to Discipline 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.
How were you referred to the NM Board of Nursing Alternative to Discipline Program
Response to the NM Board of Nursing Alternative to Discipline Program (please tell us why you are entering the ATDP)
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
Should be Empty:

NM BON Alternative to Discipline Program Response Checklist

Response Checklist

REQUIRED: Please Answer the Following Questions