SPEAK UP Faculty Application

SPEAK UP Faculty Application
Thank you for your interest in becoming SPEAK UP Faculty.

Please answer the following questions.

For assistance, email info@perinatalqi.org.
To apply to become SPEAK UP Faculty, applicants must:
- Be a current PQI Professional paid member.
- Be a current perinatal health clinician and have five years of clinical experience or a public health professional with at least three years of experience.
- Be a RN (DNP or doctorate preferred, certification desirable), physician (with valid US medical license), social worker, public health professional or midwife (with valid US license) with a bachelor's degree.
- Participated in perinatal professional development activities (CNE/CME) within the past three years.
- Attend a virtual four hour SPEAK UP Faculty Course. The cost for the Faculty Course is $499 for non-Massachusetts applicants.
Section A: Demographic Information
1. Name*

First NameLast Name
2. Credentials*
3. Home Address*

Street Address

Street Address Line 2

CityState

Postal / Zip Code
4. Home or Cell Phone Number*
5. Work Phone Number
6. Email Address*
example@example.com
7. Please select the best description of your professional background.*

Registered NursePhysicianMidwifeDoulaSocial WorkerPublic Health ProfessionalOther
8. Your Highest Degree Earned, Institution and Program that Awarded the Degree, and Graduation Date*
9. Name of Employer*
10. Business Address

Street Address

Street Address Line 2

CityState

Postal / Zip Code
11. Job Title/Position*
12. Please select from the following list the race/ethnicity category that you most closely identify with.*

Black or African American, non-HispanicLatino or HispanicWhite, non-HispanicAmerican Indian and Alaska Native with Tribe or Nation AffiliationNative Hawaiian or other Pacific IslanderEast Asian (Chinese, Filipino, Japanese, Korean, Taiwanese, Vietnamese, other)South Asian (Bangladesh, East Indian, Indo American, Nepali, Pakistan, Sri Lankan)South East Asian (Hmong, Indonesian, Malaysian, Myanmar, Singapore, Thai, other)Other, not included aboveI prefer not to answer
Section B: Prerequisite Questions

13. Please indicate if you have successfully completed the following education within the past three years. Note: You must answer YES to all of these options to apply to become SPEAK UP Faculty.*

	YES	NO
SPEAK UP Champion Implicit and Explicit Racial Bias Education (8 hours)
SPEAK UP Ambassador Implicit and Explicit Racial Bias Education (6 hours) or Are Registered and Intend on Attending the Scheduled Conference on 5/17/23
SPEAK UP Modules Course https://www.perinatalqi.org/store/viewproduct.aspx?id=19996713
Harvard Implicit Bias (/Race IAT) Self Assessment https://implicit.harvard.edu/implicit/selectatest.html
PQI's Birth Equity Webinars https://www.perinatalqi.org/page/PNQINMASPEAKUPEquityWebinars

14. Are you a current PQI Professional Paid Member? Note: You must answer yes to this question to apply to become SPEAK UP Faculty. Learn more about becoming a paid member at https://www.perinatalqi.org/general/register_member_type.asp.*

YesNo
15. List your current licensure of which you are in good standing. Include the states/provinces.*
16. Are you a current clinical practitioner of perinatal health with five years of perinatal clinical experience or a public health professional with at least three years of experience? Note: You must answer yes to this question to apply to become SPEAK UP Faculty.*

YesNo
17. Have you participated in perinatal professional development activities that awarded CNE/CME within the past 3 years? Note: You must answer yes to this question to apply to become SPEAK UP Faculty.*

YesNo

Thank you for your interest in becoming SPEAK UP Faculty. You are not eligible to apply at this time because you do not meet the required prerequisites. To complete these prerequisites and learn more about PQI, please visit our website.

For assistance, email info@perinatalqi.org.
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