"Adverse Events Reporting Form" - New Mexico

Adverse Events Reporting Form is a legal document that was released by the New Mexico Department of Health - a government authority operating within New Mexico.

Form Details:

  • Released on June 1, 2017;
  • The latest edition currently provided by the New Mexico Department of Health;
  • Ready to use and print;
  • Easy to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of the form by clicking the link below or browse more documents and templates provided by the New Mexico Department of Health.

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Download "Adverse Events Reporting Form" - New Mexico

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Adverse Events Reporting Form
The school nurse or the school nurse leader/supervisor of the school district is required to report the following adverse
events to the public health Regional Health Officer or School Health Advocate in his/her respective public health Region.
Reporting should occur within 24 hours in the event of (1) or (2) or within 3 working days in the event of (3), (4), (5) or
(6) below.
(1) Any death of a student or staff member that occurs during school hours or on school grounds.
(2) Any known suicide attempt (including completed or suspected) of a student, including those occurring after hours or
during school vacation.
(3) Any delivery of an infant on school grounds.
(4) Any medication error as the result of a school nurse or other school staff action that requires an ambulance to be
called or
requires the student to be transported to an emergency room or urgent care facility.
(5) Any error involving vaccine administration
(6) Any untoward event with the potential of impacting physical or mental health of the school community.
(7) Administration of emergency medication resulting in activation of EMS:
prescribed or
stock
Specify medication: __________________________________________
INFORMATION TO REPORT:
Date of Report:
Date of Adverse Event:
School District:
School:
Name of School Nurse:
Name/Title of Person Reporting Event:
Age of Student Involved:
Description of Adverse Event:
School/District Response & Outcome: Please include information such as mobilization of EMS or crisis teams, etc.
New Mexico Department of Health, Public Health Division
Revised June 2017
Office of School and Adolescent Health
Adverse Events Reporting Form
The school nurse or the school nurse leader/supervisor of the school district is required to report the following adverse
events to the public health Regional Health Officer or School Health Advocate in his/her respective public health Region.
Reporting should occur within 24 hours in the event of (1) or (2) or within 3 working days in the event of (3), (4), (5) or
(6) below.
(1) Any death of a student or staff member that occurs during school hours or on school grounds.
(2) Any known suicide attempt (including completed or suspected) of a student, including those occurring after hours or
during school vacation.
(3) Any delivery of an infant on school grounds.
(4) Any medication error as the result of a school nurse or other school staff action that requires an ambulance to be
called or
requires the student to be transported to an emergency room or urgent care facility.
(5) Any error involving vaccine administration
(6) Any untoward event with the potential of impacting physical or mental health of the school community.
(7) Administration of emergency medication resulting in activation of EMS:
prescribed or
stock
Specify medication: __________________________________________
INFORMATION TO REPORT:
Date of Report:
Date of Adverse Event:
School District:
School:
Name of School Nurse:
Name/Title of Person Reporting Event:
Age of Student Involved:
Description of Adverse Event:
School/District Response & Outcome: Please include information such as mobilization of EMS or crisis teams, etc.
New Mexico Department of Health, Public Health Division
Revised June 2017
Office of School and Adolescent Health