Preceptor Application

PRECEPTOR APPLICATION

PLEASE PRINT

NAME______DATE OF APPLICATION______

 Home  Business address______

PHONE: OFFICE______CELL ______FAX______HOME______E-MAIL ______Are you an ATM member (required)? No Yes

QUALIFICATIONS(Check all that apply):

TEXAS. LICENSED MIDWIFE #______Date Licensed ______Expires on ______

 NARM CPM #______Expires on ______ CNM ______

State Certificate #

Licensed in: Arkansas California Colorado Florida Montana New Mexico Oregon Washington

EXPERIENCED MIDWIFE (3+ years working as primary midwife without supervision)

PHYSICIAN ______ Other (explain) ______

State License #

HAVE YOU PREVIOUSLY TAKEN AN ATM PRECEPTOR TEST? No Yes Date ______

MODE OF MIDWIFERY EDUCATION (Check all that apply):

 ATM GRADUATE (Date Graduated) ______ APPRENTICESHIP Dates ______to ______

Name of Preceptor(s) ______

 Other Course ______Date completed ______

 Other (describe) ______

Please describe any special training or experience you have in areas related to midwifery or teaching: ______

______

______

Number of years of practice: ______Total births attended as of application date: ______

Number of births as primarymidwife(not including those attended as part of licensing, certification, or apprenticeship requirements): ______Number of births attended in any role since licensing or certification: ______

Note: if you have been practicing for less than 3 years you will need to complete the “Documentation of Births” form.

• Of the above births as primary midwife at least 10 are *Continuity of Care clients. Yes  No

* Continuity of Care is defined as at least 4 prenatal exams, the birth, the newborn exam, and 1 postpartum exam.

PRACTICE INFORMATION: Current Type of Practice(Check all that applies):

Solo Practice Group/PartnershipHome Birth Center  Hospital

Please give the name(s),address(es) of any midwives, birth centers or hospitals with whom you currently work or have worked in the past 5 years:

NAME OF MIDWIFE, CENTER OR HOSPITAL / DATES OF SERVICE
From - To / Self
Employed
Yes or No / ADDRESS

APPROXIMATELY HOW MANY BIRTHS DO YOU ATTEND PER MONTH ON AVERAGE? ______

WHAT IS THE MAXIMUM NUMBER OF BIRTHS YOU ATTEND IN ANY GIVEN MONTH? ______

HOW MANY BIRTHS PER MONTH DO YOU EXPECT YOUR APPRENTICE(S) TO ATTEND? ______

Please read and answer the following carefully. Having a complaint, past or current, does not rule you out as an ATM Preceptor. However, applicants with complaints may be asked to provide additional information.

Have you had any complaints filed against youwith any *regulatory, credentialing, or licensing agency in the past 5 years regarding your practice that have been resolved? Yes No

• If yes, attach a list with the dates and nature of the complaint(s) and a copy(ies) of any resolutions or letters of outcome.

Do you currently have any on-going, unresolved complaints filed against you with any *regulatory, credentialing, or licensing agency regarding your practice? Yes No

• If yes, attach a list with the dates, the agency with which the complaint was filed, the nature of the complaint(s), and the current status.

*This includes but is not limited to the Texas Midwifery Board, TDSHS Health Facility Licensing (regarding birth centers,) North American Registry of Midwives, American College of Nurse Midwives or American Midwifery Certification Board, State Board of Medical Examiners, State Board of Nurse Examiners.

Please submit this application along with copies of any certificates or licenses. Out-of-State CPMs, and all CNMs and Physicians must also submit a resume or CV along with this application.

Certified Professional Midwives must submit a copy of their CPM certificate

Note: All Preceptors must be members of the Association of Texas Midwives. Membership application can be found on-line at

By signing this application you certify that all of the above information is correct and that you meet the Preceptor requirements set by ATM. ATM reserves the right to make inquiries regarding complaints concerning your practice or your ability to teach midwifery students. If it is later found that you have falsified any information provided, or there is omission of requested information, ATMMTP preceptor status may be revoked.

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Signature of Applicant Date Signed

______

Signature of Course Coordinator Date Signed

Please mail this form and all required documents to:

ATM

P.O. Box 887

Elmendorf, TX 78112

For more information call 432-664-8845 or email or

______

OFFICE USE ONLY

INCLOSED DOCUMENTS:

CURRENT LICENSE COPY OF CPM CNM Cert  PHYSICIAN License

 DOCUMENTATION OF BIRTHS AS PRIMARY MIDWIFE  N/A  RESUME (if required)

PASSED ATM PRECEPTOR TESTon ______(date) N/A

 COMPLAINTS REVIEWED BY EDUCATION COMMITTEE  Waived or N/A

SIGNED ATM PRECEPTOR AGREEMENT

ASSOCIATE MEMBERSHIP

APPROVED PRECEPTOR

CERTIFICATE MAILED

FILE COMPLETE on ______(date)

DOCUMENTATION OF BIRTHS ATTENDED

This form must be completed by any applicant with less than 3 years’ experience since licensure or certification.

Midwife’s name:______Date of Application ______

CPM or CNM Yes No Date you began practice as primary midwife (mo/year) _____ Number of years in practice ____

List all births attended since licensure or certification. Do not include births as an apprentice or part of your training requirements. Please maintain client confidentiality by using a code instead of your clients’ names. You must document 50 births since licensure/certification. Note in the “Continuity of Care column any client who meets the requirements for a “Continuity of Care” client (min. of 4 prenatal exams, the birth, newborn exam, and at least 1 postpartum exam.) You must document at least 10 Continuity of Care clients in order to meet preceptor qualifications.

client
CODE / date of birth / Continuity of Care
Y
Totals
client
CODE / date of birth / Continuity of Care
Y
Totals

I certify that the above record of my experience is accurate. I understand that ATM has the right to request documentation of any of the above listed records, and that falsifying information is grounds for removal as an ATM Preceptor.

Midwife’s Signature: ______

P.O. Box 887

Elmendorf, TX. 78112

432-664-8845 FAX 830-393-3927

ATM PRECEPTOR AGREEMENT

I agree to accept apprentice midwives enrolled in the ATM Midwifery Training Program. I understand that I will not be required to accept an apprentice for training if I do not feel that she is compatible with my practice. I also understand that ATM expects Preceptors to promote the ATM Midwifery Training Program and encourage enrollment by prospective students.

As a Preceptor, I will attempt to communicate encouragement and constructive criticism in a positive and non-threatening manner. I will take responsibility for all clinical and management skills performed by the Apprenticeduring the apprenticeship phase, including the proper documentation of all clinical experience and the evaluation and assessment of those clinical skills, including approval of performance and/or recommendations for additional training and experience. As Primary Caregiver, I will inform all clients of the Apprentice’s role in their prenatal, labor, birth, postpartum, and newborn care, and obtain informed consent to allow Apprentices to take part in that care.

I agree to abide by the guidelines/definitions for “observer”, “assistant” and “primary midwife under supervision” contained in the Preceptor Handbook for determining the role the Apprentice assumes in client care. I agree to directly supervise Apprentices in every aspect of their clinical training. This means that I must be physically present when the Apprentice performs the clinical care, except for the two required planned hospital births. I understand that any deviation from this policy will result in clinical experience not counting towards the student’s clinical requirements, and that failure to provide adequate supervision to ensure the safety of my clients will be considered grounds for dismissal as a Preceptor.In the case of the two planned hospital births that an apprentice must attend I understand that I do not need to be physically present as long as the apprentice’s role is that of an observer, but that I will be responsible for verifying information prior to signing-off on this requirement.

I agree to evaluate Apprentice midwives and to participate in Preceptor evaluations every January and July as required, and to provide this information on the appropriate formsto the Course Coordinator.

I understand and agree to abide by Texas Midwifery Board polices regarding apprentice supervision and disclosure of complaints. Additionally, I understand that if any legal action is taken against my midwifery practice, or if any complaint is made to any regulatory, credentialing, or licensing agency regarding my practice during the time I am supervising an ATMMTP student that the ATMMTP requires that I notify the Course Coordinator of such action by certified mail or e-mail or fax followed by a confirmatory email within thirty (30) days of becoming aware of such action. I understand that I may be asked to provide information on the nature of the complaint or action, and will be able to come before the ATM Education Committee to give an explanation of the complaint if necessary. Failure to notify the Course Coordinator as stated will result in dismissal as an ATM approved Preceptor.

I will not use the ATM Midwifery Training Program or any materials for my own purposes or financial benefit, nor will I distribute or share any part of this program with others not currently enrolled in the program. I will guard the privacy of all students and staff and not share or discuss information I have gained through ATM while serving as a Preceptor.

Should I be unable to fulfill my duties as Preceptor, I will give one month’s notice to the Apprentice Midwife and the Course Coordinator. I will mail evidence of any completed clinical training to the Course Coordinator and give one copy of the same to the apprentice.

As a preceptor, I understand I will not be paid by ATM for the time spent supervising Apprentices during clinical training. I understand that I will be responsible for my own financial arrangements with the Apprentice.

I have received a copy of the Preceptor Handbook and have read it. I attest that I understand the information contained in the Handbook. I agree to follow ATMMTP policies and to use it as a reference in guiding Apprentices through the ATM Midwifery Training Program.

I have read and understand the Texas Midwifery Board Apprentice/Student Policy. I will review this policy with Apprentices to ensure that there is a mutual understanding and that these policies will be adhered to without exception.

I have read and understand the Texas Midwifery Board Supervising Midwife Complaint Disclosure form. I will review this form with Apprentices to ensure that there is a mutual understanding and that these policies will be adhered to without exception.

Preceptors and ATM Students shall follow and abide by legalities within their state regarding midwifery and the training of students.

Upon renewal of my license and/or certifications, I agree to send a current copy to the ATM office.

I understand that I must maintain Active Midwife membership with ATM in order to maintain my preceptor status.

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Preceptor Name Preceptor Signature Date

_Claudine Crews, LM ______

Course Coordinator Name Course Coordinator Signature Date

Rev. 2013-1 The Association of Texas Midwives Midwifery Training Program Page 1of 6