CIM Preceptor Application
This application is for preceptor sites ( birth center, maternity home, hospitals) and individual Maternity providers that wish to serve as preceptors for CIM students. Supporting documentation files should be attached to this secure application. Please contact us with any questions. Thank you for your interest in becoming a preceptor for future Certified International Midwives! Info@internationalmidwife.org 1-800-374‑1285 on WhatsApp
Individual Preceptor Name ( if applicable )
First Name
Middle Name
Last Name
Preceptor Site Name ( if applicable)
Name of person completing this application, if for a preceptor site
First Name
Last Name
Birth Date ( individual applicants only )
Please select a month
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Address of individual preceptor or the registering preceptor site
Street Address
Street Address Line 2
City
State / Province & Country
Postal / Zip Code
E-mail
*
example@example.com
Phone Number
Format: (000) 000-0000.
WhatsApp Number
Format: (000) 000-0000.
Does IRM have permission to release your contact information to CIM students seeking a preceptor?
Yes
No
Possibly, but email with details prior to release of my information
Please provide a list of your credentials and licensure, with dates of issuance, if an individual application. If this is a site application please explain what type of site you are (birth center, maternity home, hospital or other). Group sites should also list how many Maternity providers they have on site, the types of providers, date of establishment and if the site is licensed/registered with the local government.
Average number of Maternity patients in your care, explanation of your scope of practice and typical place of birth attendance.
*
If an individual preceptor application: Please provide details on your training, total births attended during training, total births attended post training, length of primary practice and additional relevant specialties. Please also provide other information you feel would assist us in the approval of your application. We will contact you if clarification is needed or if we have any additional questions.
How many students do you currently have and what is your student capacity?
Preceptor Responsibilities - The International Registry of Midwives takes maternal and neonatal healthcare and education very seriously, we are dedicated to certifying highly skilled birth workers who intend to use their skills to improve the care and education of women and their children. We believe that competent and compassionate birth workers are the key to improving maternal and neonatal care/outcomes worldwide. As a preceptor you are responsible for ensuring the student/students you are overseeing are proficient and confident in their midwifery skills while maintaining an empathetic and compassionate disposition. Do you agree to train/oversee your apprentices/students with the utmost confidence and skill, while Maintaining our criteria?
*
Yes
No
Preceptor & Apprentice Relationship - The International Registry of Midwives expects the preceptor and apprentice relationships to be healthy and professional. As the preceptor you are entrusted with creating a fair, honest, mutually respected environment for you and your apprentice to work in. The apprentice/student needs to respect you as the preceptor and you need to respect the apprentice/student as a valuable team member. Both the preceptor and apprentice should have a clear understanding of responsibility and roles. For Example: Financial obligations, Clinical observations, Time on call, One on one training, Skills demonstration. Do you agree to provide clear expectations of the apprentice/student from the beginning while maintaining a professional and respectful environment?
*
Yes
No
Upload proof of certification if applicable
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Upload proof of licensure if applicable
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Upload proof of training if applicable
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Upload copy of government issued ID (individual applications)
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Upload additional supporting documentation that you feel will assist us in approval of your preceptor application
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Upload additional supporting documentation that you feel will assist us in approval of your preceptor application
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This is a secure form. Please be sure to attach all supporting documentation to this form, via the file attachment options above. This includes copies of credentials, licensure or proof/documentation of training and experience. If this is an individual application, please include a copy of your government identification. If your Preceptor Registration form is approved, we will email you with your IRM Preceptor ID #. You will use this Preceptor ID # on all future student forms. Please contact us concerning questions involving preceptor/apprentice relationships. Preceptor applications will take 2-4 weeks to process. Please sign below in acknowledgment of your application to become an IRM CIM Preceptor.
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