DOCUMENTATION OF BIRTHS ATTENDED This form must be completed by any applicant with less than 3 experience since licensure or certification. years’ Date of Application _____________ Midwife’s name:__________________________________ 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 must document 50 births since clients’ names. You licensure/certification. Note in the of Care column any client who meets the requirements for a of client “Continuity “Continuity Care” (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. of of client client CODE date of birth CODE date of birth Care Care Continuity Continuity Y Y Totals 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. Signature: ________________________________________________________________________ Midwife’s
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: ________________________________________________________________________
Preceptor%20Application%20Forms%202013-1-21%20Complete.docx