HWPS Compliance Class Visit Form Congratulations on successfully registering for a HWPS course that contains a clinical component. You are not expected to complete any compliance requirements until the Office of Verification and Compliance has visited your class, typically during the first week of the term. In order to prepare you for clinicals, the following information is required to complete your NM Department of Health Caregivers Criminal History Screening. All required fields are marked with a red box, indicating you must provide a response in order to successfully submit the form. NOTE: After you click submit, please print a copy of the Thanks Page as proof that you submitted the form. You may be asked to provide this during your class visit. First Name Middle name Last Name Student ID number CNM E-Mail Address What CNM course/program are you registered for? If your program is not listed that means your course is a part of a Coordinated Entry Program (CPE). As a result, students are required to attend a mandatory orientation. Please email compliance@cnm.edu for the correct form to register for an orientation. Choose OneAccessibility Services- InterpretersAdult Cardiac Sonography (ECHO)Community Health WorkerDental AssistingDietary ManagerElectroneurodiagnostic TechnologyEMS-BasicEMS-IntermediateEMS-ParamedicHealth Information TechnologyHuman ServicesMedical AssistantMedical Laboratory TechnicianNursing AssistantNurse RefresherPatient Care TechPharmacy TechnicianPhlebotomyPhysical Therapy AssistantSurgical Technologist Permanent/Physical Address Address Line City State Zip Code Mailing Address Please indicate Yes if mailing address is the same as Permanent Address Please indicate No if Mailing address is different than Permanent Address. You will have to provide your mailing address below Yes No Mailing Address Mailing Address: State Mailing Address: City Mailing Address: Zip Code Social Security or ITIN Number This is required in order to perform background check through New Mexico Department of Health (NMDOH). Please enter Social Security Number: (XXX-XX-XXXX) If you do not have a Social Security Number, please enter your ITIN number Date of Birth Please provide date of birth in the following format (MM/DD/YYYY) Gender Choose OneMaleFemaleUnknown Eye Color Please select one of the options below Choose OneBlackBlueBrownGreyGreenHazelMaroonMulticoloredPinkUnknown Race Please select one of the options below Choose OneAsianBlackNative AmericanWhiteUnknown Hair Color Please select one of the options below Choose OneBaldBlackBlondeBrownStrawberryGrey or Partially GreyRed or AuburnSandyWhiteOrangeUnknown Height Please list feet and inches Weight US Citizen Please indicate if you are a US Citizen YesNo Place of Birth Please include city and state Primary Phone Please include area code when entering phone number (XXX-XXX-XXXX) Primary Phone Type Choose OneHomeCellWork Aliases/Prior Names (Includes all names by which an applicant is currently known or has been identified as) Last, First, Middle Name Social Security and Date of Birth Please provide only if SS# is different from above. Prior Addresses within the last 7 years Year to & from (ex. 2012-2014) Identification MUST UPLOAD A COPY OF THE DOCUMENT YOU ARE LISTING Identification Type Select Document Type Choose OneState Issued Driver’s LicenseState Issued Photo ID CardUS Armed Forces IDPassportVisa Identification Information Please provide the following information about the document you uploaded. Issuing State: Identification Information Document Number: (DL# or Passport #) Identification Information Expiration Date (MM/DD/YYYY): Identification Information Please select the appropriate issuing authority for the document you uploaded. Motor Vehicle Department United States of America US Immigration US Armed Forces Spam Check If you have specific compliance questions please visit the Office of Verification and Compliance's website.