Preceptor Contact Information

This form must be filled out and submitted only by the practitioner applying to precept an NMI student.

Preceptor (Preferred) Name: *

Former name(s) listed on previous records/certificates:

Preferred Mailing Address: *

Street Address

Street Address 2

City

State

Zip

Phone: *

SMS Opt-In

I would like NMI to send me SMS alerts and reminders relevant to my account. Message and data rates may apply. Reply HELP for help or STOP to cancel.

Email: *

Date of Birth *

What are your Gender Pronouns? *

Are you Hispanic or Latino? *

Ethnicity *

White

Hispanic/Latino or Spanish Origin

Black or African American

Asian

American Indian or Alaska Native

Middle Eastern or North African

Native Hawaiian or Other Pacific Islander

Some other race/ethnicity/origin

Choose not to identify

Do you identify as LGBTQIA++?

Name of student you are applying to work with: *

Clinical Site/Practice

Practice Name: *

Name of Practice Coordinator: *
In larger birth centers, this individual may be a Clinical Director or other Administrative Staff. Enter own name if this is a solo practice. This individual must complete the Clinical Site Guidelines form.

Practice Coordinator Email *

Location(s) of your practice: *

Describe the general demographic characteristics of the population you/your site serve. This information can help future students select sites where they can provide culturally congruent care.

Credentials

Complete information for the credential(s) you hold. Credentials must be current and active. Fill in all that apply.

Current Credential(s): *

CPM

LM

CM

RM

CNM

CPM/LM

MD

Other

What kind of credential do you hold?

Enter the Expiration Date for your credential: *

Upload Current Credential(s) *
Please submit a copy of your current credential (CPM Certificate or non-CPM credential).

In which state(s) are you licensed to practice midwifery or practice clinically:
MDs or DOs must have a practice that includes obstetrics and/or gynecology. If your state does not require licensure, enter "Not Applicable".

License/Credential number: *
If you practice in a state that requires licensure, please list both your credential number and your license numbers.

Enter your License Expiration Date *

Upload your License (if applicable)
Midwives practicing in states where licensure is required must provide a copy of current licensure in order to be approved.

Are you a NARM Registered Preceptor? *

Yes

No

Please upload your NARM Preceptor Registration Certificate (if applicaple)

Experience

What year did you begin practicing as a primary midwife after training? *

Approximately how many births have you attended as a Primary or Co-Primary Midwife/Practitioner? *

Do you attend Peer Review? If so, how often: *

Do you use Practice Guidelines? *

How many apprentices have you worked with in the past? *

Have any of them gone on to practice midwifery? *

Preceptor Certifying Statements

Preceptors should take the time to read the linked policies and documented noted in each Certifying Statement below. Failure to check any certifying statement will result in your application being withdrawn. READ the NMI policy that you are required to comply with BEFORE submitting this application.

By checking the boxes below, you are certifying that you have read and understand the policy and procedures outlined in NMI's Student Handbook and posted on our Policy and Procedure web page. You will be held to these policies and expected to understand their implications.

*

I have read NMI's Non-Retaliation Policy and agree to comply with it to the best of my ability.

I have read and understand NMI's policy on Faculty Initial and Ongoing Training and agree to comply with it and submit documentation of trainings as indicated in the policy..

I have read and understand NARMs Policy Statement on Preceptor/Student Relations. I agree to provide fair and honest documentation of experiences and skills required by NMI and NARM.

I hereby affirm that I have read and agree to uphold NMI's program objectives, philosophy and purpose statement, and MANA's Values and Ethics Statement.

I affirm that to the best of my knowledge, I have represented my practice, knowledge, skills, experience and expertise honestly and fairly.

I hereby affirm that I have received a copy of NMI's Student Handbook and have reviewed the sections titled Evaluations and Faculty (as they related to clinical faculty).

I have read and agree to abide by NMI's Statement of Rights and Responsibilities.

I have read and understand NMI's Anti-Oppression Statement.

Signature

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Preceptor Application

NMI Preceptor Application

Preceptor Contact Information

Clinical Site/Practice

Credentials

Experience

Preceptor Certifying Statements