17 CAR pt. 47, Appendix B
1. Transitional Apprentices
2. Preceptor-Apprentice Agreement for Transitional Apprentices
3. Apprentice Acquisition of Clinical Skills Form
Apprentices with active permits issued prior to the effective date of these Rules, henceforth referred to as "Transitional Apprentices", will have three (3) years from the date these Rules take effect to successfully complete their apprenticeship and submit an application for lay midwifery licensure to ADH, and request approval to sit for the NARM written examination under the requirements listed in this Appendix. If they have not done so by that date, it will be necessary for the applicant to fulfill the requirements listed in Section 201 (Initial Licensure).
1. The apprentice must submit a signed Preceptor-Apprentice Agreement to ADH within thirty (30) days of signing for each preceptor under which the apprentice trains during the course of their apprenticeship. The ADH Preceptor-Apprentice Agreement form (found in this Appendix) or available on the ADH website) shall be used for this notification.
2. Should the Preceptor-Apprentice Agreement be terminated by either party, it is the responsibility of both parties to notify ADH immediately. An apprentice must not continue to perform under any preceptor(s) unless a new signed Preceptor-Apprentice Agreement is on file with ADH.
3. Preceptors must be an Arkansas-licensed midwife or certified nurse-midwife, or if outside of Arkansas, preceptors must be licensed by the state of residency as a direct-entry midwife or certified nurse midwife, or have a Certified Professional Midwife credential from the North American Registry of Midwives.
4. Any changes in the apprentice's contact information must be provided to ADH by the apprentice within thirty (30) days of the status change.
5. Apprentices shall follow all applicable Arkansas laws and these Rules.
6. Apprentices are required to comply with all provisions of HIPAA (Health Insurance Portability and Accountability Act).
7. Permit Renewal
For those apprentices holding valid Apprentice Permits, on or before the effective date of these Rules, the permit must be renewed by the permit's expiration date if necessary. Renewal will only occur upon application and favorable review by ADH. This review will assure that the lay midwife apprentice is acting under the supervision of the preceptor and in accordance with these Rules. The permit will be valid until three (3) years from the effective date of these Rules. If an apprentice has not obtained Arkansas licensure by that date, the applicant will no longer be considered a transitional apprentice and must follow the guidelines for licensure found in Section 201 (Initial Licensure).
To renew the permit, the Apprentice shall submit the following evidence at least sixty (60) days before the expiration date of the permit:
a. A completed application (Appendix A).
b. A copy of both sides of current certification in adult and infant cardiopulmonary resuscitation (CPR). Approved CPR courses include courses that are approved by NARM. Note: Only certification from courses which include a hands-on skills component are accepted. Online-only courses are not accepted. It is the responsibility of the apprentice to ensure this certification is current at all times and documentation must be provided upon request.
c. A copy of both sides of current certification in neonatal resuscitation through a course approved by NARM. Note: Only certification from courses which include a hands-on skills component are accepted. Online-only courses are not accepted. It is the responsibility of the apprentice to ensure this certification is current at all times and documentation must be provided upon request.
d. Documentation of clinical experience for the time period covered for the current permit period. This includes progress made toward licensure for those years, i.e. number of antepartum (AP) visits conducted, labor managements and deliveries, newborn evaluations and postpartum examinations conducted under supervision.
e. Verification of all current Preceptor-Apprentice relationships documented by a Preceptor-Apprentice Agreement form for each preceptor signed within 90 days of application submission.
Transitional apprentices who are approved by ADH to sit for, and who pass, the NARM written examination will be issued a license upon completion of all other requirements.
A transitional apprentice who receives licensure must go through NARM and become certified as a CPM in order to be eligible to renew their license at the end of their initial licensure period. License renewal will follow the procedures outlined in Section 202.
Once the CPM certification is received, a notarized copy of the certificate or a verification letter sent directly from NARM must be submitted to ADH within thirty (30) days of certification.
Eligibility requirements for approval for transitional apprentices to sit for the NARM written examination:
a. A completed application.
b. Additional documentation as follows:
i. A passport style and size photo of the applicant, head and shoulders, taken within sixty (60) days of the submission date of the application and attached to the application.
ii. A copy of one of the following documents that demonstrates the applicant is 21 years of age or older:
A. The applicant's birth certificate.
B. The applicant's U.S. passport, U.S. Driver's License or other state-issued identification document.
C. Any document issued by federal, state or provincial registrar of vital statistics showing age.
c. A copy of both sides of current certification in adult and infant cardiopulmonary resuscitation (CPR). Approved CPR courses include courses that are approved by NARM. Note: Only certification from courses which include a hands-on skills component are accepted. Online-only courses are not accepted. It is the responsibility of the licensee to ensure this certification is current at all times and documentation must be provided upon request.
d. A copy of both sides of current certification in neonatal resuscitation through a course approved by NARM. Note: Only certification from courses which include a hands-on skills component are accepted. Online-only courses are not accepted. It is the responsibility of the licensee to ensure this certification is current at all times and documentation must be provided upon request.
e. Documentation of a high school diploma, or its equivalent, and documentation of the highest degree attained after high school. This documentation should include the name of the issuing school or institution and the date issued. Applicant's name must be the same as on the copy of the diploma or degree. If applicant's name is not the same, applicant must submit proof of name change with application.
f. Verification of professional health-related licensure in other jurisdictions may be requested by ADH.
Applicants for licensure must demonstrate competency in performing clinical skills during the antepartum, intrapartum, postpartum, and the immediate newborn periods. Each applicant must successfully complete an evaluation of clinical skills. The applicant must submit a statement that the following minimal practical experience requirements have been performed under the supervision of a physician, CNM, or LLM.
These forms should be submitted only after the applicant has a 'pass' on each item, except for certain emergencies that may not occur during a preceptorship. The following required forms must be submitted:
PRECEPTOR-APPRENTICE AGREEMENT FOR TRANSITIONAL APPRENTICES
The apprentice must submit a signed Preceptor-Apprentice Agreement for each preceptor under whom they train. The preceptor is responsible for the training of the apprentice and for supervision of the apprentice's performance as an assistant or primary midwife in the attainment of the required clinical experiences and demonstration of skills. The preceptor shall provide instruction prior to the performance of clinical skills, and shall sign off on the required clinical experiences and skills.
Should any Preceptor-Apprentice Agreement be terminated by either party, it is the responsibility of both parties to notify ADH immediately. An apprentice must not continue to perform under any preceptors unless a signed Preceptor-Apprentice Agreement is on file with ADH.
Apprentices shall follow all applicable Arkansas laws and these Rules.
Apprentices are required to comply with all provisions of HIPAA (Health Insurance Portability and Accountability Act).
Apprentice Information (PRINT):
Name ___________ Address ___________ City _____ State ___ Zip __ Phones: (h) ___ (c) ____ email: ________
Preceptor Information (PRINT):
Name ___________ Address ___________ City _____ State ___ Zip __ Phones: (h) ___ (c) ____ email: ___ Licensed by (state) ___ Date of expiration ____ CPM number ___ Date of expiration _____ MBC: ☐ Yes ☐ No
If preceptor is not licensed in Arkansas, a notarized copy of state license or CPM certificate must be submitted or a verification letter sent by NARM directly to ADH.
I agree to provide training in all of the required clinical knowledge and skills, and to supervise by direct, on-site, supervision, all clinical experiences that will have my signature on the clinical documentation experience forms for:
Apprentice's signature ________ Date ________
Signature of Preceptor ________ Date ________
Renewed permits will be valid until three (3) years from the effective date of the Rules Governing the Practice of Licensed Lay Midwifery in Arkansas.
| Last Name | First | Middle | Date of Birth | Date |
|---|---|---|---|---|
| It is your responsibility to notify us of any change in name or address | Social Security Number | |||
| Address (include Street, City, State, Zip) | Home Phone ( ) | |||
| Business Phone ( ) | ||||
| Mailing Address, if different from above | Other Phone (pager, etc.) ( ) | |||
| Email Address | ||||
| Current Health Related Licenses | State | License Number | Expiration Date | |
| Have you ever had a license revoked in any health-related field since last application? ☐ Yes ☐ No If yes, specify ___ ___ | Have you ever been convicted of a felony since last application? ☐ Yes ☐ No If yes, specify ___ ___ |
Date ______ Signature of Applicant
Transitional Apprentices will have three (3) years from the effective date of the Rules Governing the Practice of Licensed Lay Midwifery in Arkansas to successfully complete their apprenticeship and submit an application for lay midwifery licensure to ADH. If necessary, the apprentice permit may be renewed during this period and will be valid until three (3) years from the effective date of the Rules. The permit must be renewed by the permit's expiration date. All renewal requirements must be received by ADH at least 60 days before the permit's expiration date.
In order to be reviewed an application for renewal must be complete and accompanied by all supporting documentation.
Type or print the application and review thoroughly before submitting. An incomplete application will delay processing.
All applicants must submit the following items before your application will be considered:
☐ 1. Complete application form. ☐ 2. Copy of both sides of current certification in adult and infant cardiopulmonary resuscitation. Only certifications from courses which include a hands-on component are accepted. Online-only courses are not accepted. Approved CPR courses include the American Heart Association and the American Red Cross. It is the responsibility of the apprentice to ensure this certification is current at all times and documentation must be provided upon request. ☐ 3. Copy of both sides of current certification in neonatal resuscitation through a course approved by NARM. Only certifications from courses which include a hands-on component are accepted. Online-only courses are not accepted. It is the responsibility of the apprentice to ensure this certification is current at all times and documentation must be provided upon request. ☐ 5. Verification of all current Preceptor-Apprentice relationships documented by Preceptor-Apprentice Agreement forms for each preceptor signed within 90 days of application submission. ☐ 6. Notarized documentation of clinical experience for the time period covered for this licensing period. This includes progress made toward licensure that year, i.e. number of AP visits conducted, labor managements and deliveries, newborn evaluations and post-partum examinations conducted under supervision.
NOTE:
☐ Applicant's name must be the same on all documents or the applicant must submit proof of name change with application. ☐ A Preceptor-Apprentice Agreement form must be signed by each preceptor under which the apprentice trains during the course of the apprenticeship and sent to ADH by the apprentice within 30 days of signing. An apprentice shall submit written notice to ADH within 30 days after any change to the relationship with a preceptor.
Mail all forms and attachments to:
ARKANSAS DEPARTMENT OF HEALTH WOMEN'S HEALTH SECTION, SLOT 16 4815 W. MARKHAM ST. LITTLE ROCK, AR 72205
All apprentices must have a Preceptor-Apprentice agreement on file with ADH for each preceptor under whom the apprentice trains. These preceptors are responsible for the training of the apprentice and for the required clinical experiences. Other midwives licensed in the state of Arkansas may sign for some of the clinical experiences.
The dates from the first assist to the final primary birth should encompass at least one year.
Preceptors are expected to sign the documentation forms at the time the skill is performed competently. Determination of 'adequate performance' of the skill is at the discretion of the preceptor, and multiple demonstrations of each skill may be necessary. Documentation of attendance and performance at births, prenatals, postpartums, etc., should be signed only if mutually agreed that expectations have been met. Any misunderstanding regarding expectations for satisfactory completion of experience or skills should be discussed and resolved as soon as possible.
The preceptor is expected to provide adequate opportunities for the apprentice to observe clinical skills, to discuss clinical situations away from the clients, to practice clinical skills, and to perform the clinical skills in the capacity of a primary midwife, all while under the direct supervision of the preceptor. This means that the preceptor should be physically present when the apprentice performs the primary midwife skills. The preceptor holds final responsibility for the safety of the client or baby, and should become involved, whenever warranted, in the spirit of positive education and role modeling.
Twenty (20) of the 75 prenatal exams are required to be initial exams and include the midwife's prenatal exam, initial interview and history (Appendix B, #9.c.).
Births as an Active Participant are births where the apprentice is being taught to perform the skills of a midwife. Charting, other skills, providing labor support, and participating in management discussions may all be done in Active Participant births in increasing degrees of responsibility. Catching the baby should be a skill that is taught towards the end of the active participant period, but not counted as a supervised primary. The apprentice does not have to perform all skills at every birth in this category, but should be present throughout labor and birth and should perform at least some skills at every birth. The apprentice should complete most of the active participant births before functioning as Primary Midwife under supervision.
Births as Primary Midwife under supervision means that the apprentice demonstrates the ability to perform all aspects of midwifery care to the satisfaction of the preceptor, who is physically present and supervising the apprentice's performance of skills and decision making. Some skills at these births may be performed by the preceptor or other midwives/apprentices, but the catching of the baby, most skills, and labor management should be performed by the apprentice who is claiming the birth as a primary birth under supervision.
It is recommended that the apprentice make blank copies of all forms in the Application in the event that more space is needed for documentation of clinical experience, or when more preceptors are involved.
*see Preceptor-Apprentice Documentation Information prior to signing this form
Name of Apprentice _____
| Client Initials | Assist at Initial Midwife Exam | Number of Additional Prenatals | Assist at Birth | Date of birth | Place of birth | Assist Newborn Exam | Number of Postpartum Exams | Supervising Midwife's Signature |
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| Example | Yes | 4 | Yes | 1/3/06 | home | Yes | 2 | |
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| Your numbers |
There are no minimum numbers for any clinicals except assisting at birth, however, it is expected that the supervising midwife will provide training both outside of and during the performance of these other clinicals. The apprentice should provide the number of clinical experiences at which she assisted for each client listed. More than twenty spaces are provided in case some clinicals are performed on clients for which the apprentice does not attend the birth. Put a "yes" or "no" in columns unless a number, date, or other information is required. Do not leave spaces blank. Place of birth: indicate home, birth center, or hospital. Transports may count as an assist if the apprentice assisted during labor at home or birth center prior to transport. There may be a period of training where the apprentice observes but does not perform assistant activities at clinical experiences. Observations should not be documented as assists.
*see Preceptor-Apprentice Documentation Information prior to signing this form
Name of Apprentice ____________
| Client Initials | Perform Initial Midwife Exam | Number of Additional Prenatals | Manage Labor and Birth | Date of birth | Place of birth | Perform Newborn Exam | Number of Postpartum Exams | Supervising Midwife's Signature |
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| Example | Yes | 8 | Yes | 1/3/06 | home | Yes | 2 | |
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| Minimum required | 20 | 55 | 20 | 20 | 40 | |||
| Your numbers |
The apprentice should provide the number of clinical experiences at which she assisted for each client listed. More than twenty spaces are provided in case some clinicals are performed on clients for which the apprentice does not attend the birth. Put a "yes" or "no" in columns unless a number, date, or other information is required. Do not leave spaces blank. For at least three clients, the apprentice should have provided a minimum of 4 prenatals, birth, newborn, and 2 postpartum exams. Place of birth code: please indicate home, birth center, or hospital. Transports to the hospital may not count toward required primary births, but may be documented for prenatal exams, etc.
Apprentice's name ____________
The following skills must be documented by a qualified preceptor as being competently performed by the apprentice. Performance of the skills includes a demonstration and/or verbal discussion of the knowledge implied by the performance of the skill. Please indicate "by discussion" if skill is not performed.
The preceptor should date and initial each line of any skill she is verifying. More than one preceptor may sign in order to complete the form. All preceptors who sign should also be listed on the Preceptor Verification Form.
General Skills
Pharmacology
Demonstrates knowledge of the benefits and risks of the following and refers for prescription and administration when indicated:
Postpartum Rubella immunization when non-immune ___
Antepartum
Assessment Skills:
Estimates fetal size _____ Lower extremities for varicosities _____ Edema of face legs and hands _____ Determines estimated due date _____ Assesses well-being _____
Evaluates knowledge of self- breast exam techniques _____ Instruction of clean catch urine specimen _____ Recognizes the indications for genetic counseling and refers as appropriate _____ Understands and applies knowledge of good eating practices _____ Evaluates and makes recommendations for discomforts of pregnancy _____ Demonstrates knowledge and application of ADA Clinical Practice Recommendations for gestational diabetic screening and diagnosis _____ Demonstrates knowledge of normal and abnormal of required prenatal screening tests _____
Educates regarding home birth supplies _____
Suspected abnormality on physical examination _____ Size/Date discrepancy _____ Elevated Blood Pressure Readings _____ Abnormal Kick Count _____ Abnormal weight gain or loss _____ Abnormal Prenatal screening tests _____ Symptoms of urinary tract infections _____ Hyperemesis _____ Abnormal Fetal Heart Rate Patterns _____ Absence of Fetal Heart Rate _____ Position other than vertex presentation _____ Preterm labor _____ Symptoms of Ectopic (Tubal )pregnancy _____ Abnormal vaginal bleeding _____ Prolonged or Premature rupture of membranes _____ Post term pregnancy _____
Takes history relevant to labor _____ Assesses effacement and dilation of cervix _____ Assesses station of presenting part _____ Assesses fetal lie, position, and descent _____ Assesses uterine contractions for frequency, duration, and intensity _____ At required intervals, monitors and assesses fetal heart rate during and between contractions _____
Assesses food and fluid intake and output _____
Assesses maternal well-being and responds appropriately:
Vital signs _____
Emotional well being _____
Assesses labor progress _____
Demonstrates basic labor support skills and comfort measures _____
Uses maternal position changes to facilitate labor _____
Demonstrates perineal support and hand techniques for delivery _____
Demonstrates proficiency in assisting normal, spontaneous vaginal birth _____
Supports father and other family members _____
Organizes birth equipment _____
Follows sterile technique _____
Abnormal fetal heart rates/patterns _____
Prolapsed cord _____
Breech presentation and birth _____
Face presentation and birth _____
Multiple birth _____
Shoulder dystocia _____
Abnormal bleeding _____
Nuchal hand, arm, or cord _____
Edematous cervical lip _____
Rupture of membranes _____
Meconium stained fluids _____
Abnormal changes in vital signs (maternal) _____
Maternal dehydration and/or exhaustion _____
Prolonged labor in:
Primagravida _____
Multigravida _____
Abnormal progress of labor _____
Symptoms of Pre-eclampsia _____
Suspected fetal death _____
Determines signs of placental separation _____
Assesses placenta for size, structure, completeness, cord insertion, and number of vessels, and color _____
Assesses uterus from birth throughout the immediate postpartum period for height, size, consistency, and retained clots _____
Identifies bladder distention and consults or refers if indicated _____
Assesses and estimates blood loss _____
Assesses lochia: amount, odor, consistency, color _____
Recognizes postpartum hemorrhage _____
Recognizes symptoms of shock _____
Assesses perineum and cervix for lacerations _____
Identifies potential perineal infection or suture breakdown _____ Identifies abnormal uterine size after delivery of placenta _____ Identifies signs of uterine infection _____ Identifies need for Family Planning counseling and refers as indicated _____
Appropriately assists with placental delivery _____ Demonstrates competency in repair of 1st and 2nd degree perineal lacerations _____ Demonstrates plan for referral for extensive lacerations _____ Takes appropriate action for postpartum hemorrhage (fundal massage, bimanual compression, expression of clots, activating emergency transport plan) _____
Demonstrates correct maternal positioning for treatment of shock and activates emergency transport plan
Instructs the mother on postpartum conditions requiring medical evaluation (i.e. excessive bleeding, increasing pain, severe headaches or dizziness or inability to void)
Develops guidelines for emergency transport of mother or baby
Performs maternal exam at 12-24 hours
Performs Postpartum evaluation at 2-6 weeks
Abnormal uterine involution _____ Maternal fever _____ Signs of uterine infection _____ Signs of breast infection _____ Hemorrhage _____ Third and fourth degree lacerations _____ Signs and symptoms of shock _____ Activates emergency transport plan _____
Recognizes signs and symptoms of respiratory distress, possible infection, seizures or jaundice in newborns
Determines APGAR scores at one and five minutes
General appearance _____ Alertness _____ Flexion of extremities and muscle tone _____ Sucking _____ Palate: visualization and palpation _____ Skin color, lesions, birthmarks, vernix, lanugo, and peeling _____ Measurements of length, head and chest circumference _____ Weight _____ Head: molding, fontanels, hematoma, caput, sutures _____ Eyes: jaundice of whites, pupils, tracking, spacing _____
Ears: positioning, responds to sound, appear patent _____ Observe chest for symmetry _____ Listen to and count heart rate and respirations _____ Fingers and toes, normal structure and appearance, creases, prints _____ Genitalia: normal appearance, testicle descent in males _____ Takes and records temperature _____ Takes and records femoral pulse _____ Assesses baby for jaundice _____ Gestational age assessment and refers for less than 36 weeks gestation _____ Performs newborn exam at 24-48 hours _____
Assures that the baby's airway is clear, uses suction when indicated _____ Promotes temperature regulation of newborn _____ Supports the establishment of emotional bonds among the baby, mother, and family _____ Cuts, clamps, and cares for cord _____ Collects cord blood when indicated _____ Documents administration of eye prophylaxis _____ Performs or refers for the state required Newborn Screening test _____ Completes Infant Hearing Loss Screening Form _____ Educates mother/parents regarding cord care _____ Assists mother in establishing breastfeeding _____ Provides breastfeeding instruction information _____ Instructs mother in normal and abnormal feeding patterns _____ Assists with breastfeeding positioning and milk expression _____
Apgar score of less than 5 at one minute or 7 at 5 minutes _____ Jaundice at 0-24 hours _____ Meconium staining on the skin _____ Abnormal heart rate _____ Birth weight less than 5 lbs or greater than 10 lbs _____ Abnormal voiding or stool pattern _____ Temperature over 100 or less than 97.7 _____ Abnormal cry _____ Abnormal feeding patterns (vomiting, poor suck, lethargy) _____ Jaundice at 24-48 hours _____ Abnormal respiratory pattern (tachypnea or apnea) _____ Signs of bleeding (i.e. petechia, bruises) _____ Rupture of membranes more than 24 hours before birth _____
Exhibits communication skills with women, peers, other health care providers
Functions as women's advocate during pregnancy, birth, and postpartum period
Assesses maternal support system
Consults with other health care professionals regarding problems
Understands and can demonstrate knowledge of:
Emotional and physical changes during pregnancy and postpartum
Signs of labor
Fetal development
Preparing home and family members for birth, as is culturally relevant
Preparation for breastfeeding
Effects of smoking, drugs, and alcohol consumption
Signs and symptoms that necessitate an immediate call to the midwife
Preparation for the postpartum period
Exploration of fears, concerns, and psycho-social status with family, as appropriate
Benefits of exercise
Sexuality education appropriate to pregnancy and postpartum
Information about required prenatal tests and lab work
Circumcision information, as culturally appropriate
Information regarding eye prophylaxis
Information regarding vitamin K
Information regarding the LLM Newborn Care Kit provided by
ADH
Information regarding the state required PKU for newborn screening
Information regarding the Newborn Screening test
Information regarding Screening for Infant Hearing Loss
Demonstrates knowledge on completion of the Birth Certificate
Demonstrate knowledge on completion of the Acknowledgement of Paternity
Affidavit
Demonstrate knowledge of LLM Caseload and Birth Log and ADH submission
requirements
Demonstrate knowledge of Incident Report and ADH submission
requirements
Understand components of Emergency Back-up Plans
Understand components of LLM Disclosure Form
Understand the LLM record keeping requirements
Understand the ADH record audit requirements
Understand requirements for CLIA certification to perform laboratory tests
By signing this form for the Documentation of Acquisition of Clinical Knowledge and Skills, I recognize that I have completed the orientation process for each of the skills listed. I have demonstrated knowledge, understanding and competency in the skills and procedures as verified thru demonstration or discussion by my supervising preceptor(s). I have demonstrated knowledge of and adherence to the Rules Governing the Practice of Licensed Lay Midwifery in Arkansas.
Signature of Preceptor
date
*Notarize here if you are an Apprentice applying for the Lay Midwife License
Notary seal for verification of preceptor's signature:
Signature of Notary
date signed
date of expiration
All apprentices must have a Preceptor-Apprentice agreement on file with the Department of Health for each preceptor under whom they train. Preceptors are responsible for the training of the apprentice and for the majority of the required clinical experiences. Other midwives licensed in the state of Arkansas may sign for some of the clinical experiences and skills. If any preceptor not licensed in the state of Arkansas is also a signer of any clinical experiences or skills, that preceptor must have a Preceptor-Apprentice Agreement on file with ADH. The following information must be filled out for any preceptor who signs any portion of the Application as documentation of clinical experiences or skills. Preceptors must be licensed in a state as a licensed midwife or CNM, or must have the credential Certified Professional Midwife (CPM). Number of births listed below means the number supervised for THIS APPRENTICE, not the total experience of the supervising midwife. Fill out all lines for documentation of clinical experiences, indicating zero if none supervised, before signing.
Name __________ Address ___________ Phone _____ E-mail ____ Licensed in which state? ____ License number __ CPM: ☐ Yes ☐ No CPM # ___ date of expiration __ Dates of supervision ______ to ____ Number of births supervised as assistant ___ number primary _ Number PRIMARY: initials _, prenatals __, newborns __, postpartums __ Signature of Preceptor _____________
Name __________ Address ___________ Phone _____ E-mail ____ Licensed in which state? ____ License number __ CPM? _ CPM # ____ date of expiration ___ Dates of supervision ______ to ___ Number of births supervised as assistant ___ number primary _ Number PRIMARY: initials _, prenatals __, newborns __, postpartums __ Signature of Preceptor _____________
Name __________ Address ___________ Phone _____ E-mail ____ Licensed in which state? ____ License number __ CPM? _ CPM # ____ date of expiration ___ Dates of supervision ______ to ___ Number of births supervised as assistant ___ number primary _ Number PRIMARY: initials _, prenatals __, newborns __, postpartums __ Signature of Preceptor _____________
Name __________ Address ___________ Phone _____ E-mail ____ Licensed in which state? ____ License number __ CPM? __ CPM # ___ date of expiration ____ Dates of supervision ______ to ___ Number of births supervised as assistant ____ number primary __ Number PRIMARY: initials __, prenatals __, newborns __, postpartums __ Signature of Preceptor ________
Name __________ Address ___________ Phone _____ E-mail ____ Licensed in which state? ____ License number __ CPM? __ CPM # ___ date of expiration ____ Dates of supervision ______ to ___ Number of births supervised as assistant ____ number primary __ Number PRIMARY: initials __, prenatals __, newborns __, postpartums __ Signature of Preceptor ________
Name __________ Address ___________ Phone _____ E-mail ____ Licensed in which state? ____ License number __ CPM? __ CPM # ___ date of expiration ____ Dates of supervision ______ to ___ Number of births supervised as assistant ____ number primary __ Number PRIMARY: initials __, prenatals __, newborns __, postpartums __ Signature of Preceptor ________
Name __________ Address ___________ Phone _____ E-mail ____ Licensed in which state? ____ License number __ CPM? __ CPM # ___ date of expiration ____ Dates of supervision ______ to ___ Number of births supervised as assistant ____ number primary __ Number PRIMARY: initials __, prenatals __, newborns __, postpartums __ Signature of Preceptor ________