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National Midwifery Institute

National Midwifery Institute

Clinical Site Form

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Clinical Site Form

Clinical Site Form

Name of Practice *

Name of Practice Coordinator *

Clinical Site Coordinator Email *

Preferred Mailing Address: *

Street Address

Street Address 2

City

State

Zip
Physical Location: *

Street Address

Street Address 2

City

State

Zip

How would you describe this midwifery practice? Check all that apply.

Urban

Suburban

Rural

Other

Please elaborate (if other selected above):

Where do clients intend to give birth? Check all that apply.

Home

Birth Center

Hospital

Other

Please elaborate (if other selected above):

Besides prenatal, birth, and postpartum care for clients and their babies, please list any other reproductive health or community services you offer:

Will apprenticeship in these skills be offered to your students?

Yes

No

How many clients do you typically have in a calendar year? *

How many births do you typically have in a calendar year?

What is your student to preceptor ratio?
If student to preceptor ratio is higher than 2:1 please include a justification of ratio (justification must describe responsible care of clients, provision of rest for the student, adequate student oversight, and adequate opportunities for student to acquire clinical experience).

Describe how your staffing levels are adequate for ensuring responsible care of clients:

Is your site located in a commercial space (sites other than preceptors' and clients' home)? *

Yes

No

Required Documentation

If your site is located in a commercial space you MUST upload documentation for the following. Clinical Site Forms will not be approved if required documentation is not included.

Upload proof of inspection for building and fire safety.
For learning sites that are located in public or commercial buildings, evidence must be provided of inspection by local authorities for building and fire safety. A public or commercial building is defined as “a building or area zoned as a business property."

If you do not have access to this proof of inspection upload a completed Clinical Site Safety Checklist.

Upload facility business license, license to operate or facility accreditation.

Clinical Site Certifying Statements

By checking the boxes below, you are certifying that you have read and understand the policy and procedures outlined in NMI's Clinical Site Guidelines Policy & Procedure and that the clinical site agrees to follow and adhere to these policies.

I certify that the clinical sites and its preceptors operate legally.

I certify this clinical site ensures that midwifery care practices are culturally responsive and respectful.

I certify this clinical site has a non-discrimination statement or policy outlining the sites’ committment to eliminating barriers, overt and implicit bias, and discrimination.

I certify that the clinical site maintains in stock and in safe working order all equipment and supplies necessary for provision of midwifery care.

I certify that the clinical site ensures quality and process standards for accepting donated equipment, pharmaceuticals, and other medical supplies.

I certify that the clinical site ensures Safety Standards for Facilities, Equipment, and Supplies in line with Federal, State and Local Requirements.

I certify that the clinical site adheres to Universal Precautions, Hazardous Waste and Hazardous Materials Management.

I certify that the clinical site ensures that at least one active NMI-approved preceptor is present with the student at all clinical experiences.

I certify that preceptors at our practice take a course every 3 years that address enabling safe, culturally responsive and respectful treatment of students.

I certify that our clinical site provides specifications and provision of rest for students.

I certify that I have read and agree that the clinical site complies with Direct Supervision of Students as outline in NMI Policy and Procedures.

I certify that the clinical site provides adequate opportunities to provide supervised primary care to clients.

I certify that I have read and agree that the clinical site maintains access to perinatal testing in accordance with current standards for CPMs.

I certify that the clinical site maintains access to medical consultation, appropriate referral and hospital transfer.

I certify that the clinical site ensures practice scope is within the scope of community standards of care, as outlined on page 8 of the Clinical Site Guidelines Policy.

I certify that the clinical site provides adequate opportunities for students to acquire Continuity of Care (CoC) experience (CIB, page 66).

I certify that the clinical site adheres to informed consent practices in all client encounters (CIB, pages 51-53).

I acknowledge that this agreement does not contain all the policies, procedures, and clinical requirements applicable to NMI, its students, or its program. Additional provisions governing the relationship between NMI and the Clinical Site are outlined in the Clinical Site Guidelines Policy & Procedure which is available online and incorporated into this Agreement by reference. By signing below, I certify that I have read the Clinical Site Guidelines Policy and Procedure and the statements above are true.

Signature of Site Coordinator:

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