MMBP Online Application Form Working Document September 2008

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1 MMBP Online Application Form Working Document September 2008 This document includes all the questions that you will find in the MMBP Online Application. It is a list of application questions, designed to help you prepare offline. This document has been created because we think that some applicants will find it easier to think about answers to the questions and to gather information prior to entering the information into the Online Application. You may use this document as a checklist, as a draft application, or in another manner. Be aware though that the actual online application has more info for many questions; if you are not sure what is being asked for, the online application will likely offer more information to assist you. WARNING: This is NOT an application form and will not be accepted for entry to MMBP. All applicants must apply via the MMBP Online Application. There may be some differences between the questions in this document and the actual Online Application. Step One: Province of Application 1. Choose the western province or northern territory in which you wish to practice midwifery, and through which you will apply to the MMBP. A. British Columbia B. Alberta C. Saskatchewan D. Manitoba E. North West Territories* *Note: Due to legislative and capacity issues, the Northwest Territories cannot assess your application themselves and they will need to arrange for a province to assess your application on their behalf. If you want to work in the Northwest Territories after completing the bridging program, you must first obtain an offer of employment as a midwife in the NWT. After you have an offer, you should contact NWT s Health Professional Licensing branch to learn how to apply to the MMBP. You should NOT choose a province and proceed with your MMPB application until these arrangements are confirmed by NWT Health Professional Licensing. (You may carry on with this working document if you are waiting to hear which province will assess your application on behalf of NWT.) 2. For applicants wanting to live in NWT: If you intend to practice midwifery in the NWT and have contacted the NWT s Health Professional Licensing branch, what province has NWT Professional Licensing branch told you to select? A. British Columbia B. Alberta C. Saskatchewan D. Manitoba September 2008 Page 1 of 28

2 Step Two: Personal Profile Name (Last name, Given Names): Previous names (Other Legal Names Appearing in Documents provided as part of this application): Previous Name Start Date (of use of other legal name) End Date (of use of other legal name) Date of Birth (YYYY-MM-DD): Gender: Female Male Permanent Address: Current address (If different from permanent address above): Home Telephone: Mobile Telephone Alternate Telephone: Address: Status in Canada: (choose one) Canadian Citizen; Permanent Resident; Work Permit; Visitor Permit; Student Visa; No Status at this time Citizenship: September 2008 Page 2 of 28

3 Step Three: Midwifery and Related Education Was your midwifery education direct entry, post-nursing, or self-directed (complete only one of the following three options)? A. Direct Entry Midwifery Education (answer the following questions only if your midwifery education program was direct entry) Name of midwifery school: Date midwifery program started: Date of completion of midwifery program: Address of midwifery school: Name of Midwifery Program Contact Person: Name of Credential granted (in original language): If your school is known, or has been known, by any other names during your program or since, please list these names and dates of use: If your school no longer exists, please give the name and contact information for the institution/organisation that is responsible for the school's archives: If you wish to provide additional information about your direct entry midwifery education you may do so here: B. Post-Nursing Midwifery Education (answer the following questions only if your midwifery education program was post nursing) Name of nursing school: Date nursing program started: September 2008 Page 3 of 28

4 Date of completion of nursing program: Complete address of nursing school: Nursing qualification granted: Name of midwifery school: Date midwifery program started: Date of completion of midwifery program: Complete address of midwifery school Name of Midwifery Program Contact Person: Name of Credential granted (in original language): If your school is known, or has been known, by any other names during your program or since, please list these names and dates of use: If your school no longer exists, please give the name and contact information for the institution/organisation that is responsible for the school's archives: If you wish to provide additional information about your nursing or post-nursing midwifery education you may do so here: September 2008 Page 4 of 28

5 C. Self Directed Midwifery Education (answer the following questions only if your midwifery education program was self-directed) ATTENTION: If you have self-directed education, you must meet the Midwifery Background - Option B requirements to be eligible to participate in the MMBP pilot. (See Eligibility Req.pdf ) To be eligible for participation in the MMBP under Midwifery Background-Option A, the content of your self-directed midwifery program needs to be pre-approved by a Canadian midwifery regulatory organisation. Unfortunately, while the College of Midwives of Manitoba has a pre-approval process, it will not be available until related legislative changes are approved by the government. This means that if you have self-directed education and do not meet Option B requirements, you cannot apply to the MMBP at this time. What Canadian midwifery regulator pre-approved your program of study? College of Midwives of Manitoba None I meet criteria for Option B Date that your program was pre-approved (if applicable): Date program started: Date of completion of program: Please summarize the main academic components of your program: Please summarize the clinical components of your program: September 2008 Page 5 of 28

6 If you wish to provide additional information about your midwifery education, you may do so here: Warning: If you have completed the section on self-directed education and do not meet eligibility requirements for Option B, you will not be eligible for MMBP. Other Relevant Formal Education Indicate any other formal education that you feel is relevant to midwifery. Do not include continuing education workshops or individual courses. (Note: The Online Application will allow you to create multiple records to be able to list more than one program.) Name of program: Name of school: Date program started: Date of completion of program: Address of school: Qualification granted: If you wish to provide additional information about your other formal education, you may do so here: September 2008 Page 6 of 28

7 Step Four: Continuing Education in the past five years Provide the information requested below about relevant educational activities undertaken since obtaining your midwifery qualification that have enabled you to keep up-to-date on evidence-based midwifery standards of care. (The Online Application will enable you to make multiple records). Include workshops, courses, conferences, participation in obstetrical/pediatric rounds, and other similar activities. Name of Activity Name of Delivering Institution, Agency, or Person Start Date of Activity End Date of Activity Description of Activity If you wish to provide additional information about your continuing education, you may do so here: September 2008 Page 7 of 28

8 Step Five: Midwifery Registration Provide information about all places where you have been registered as a midwife. Start with your current or most recent registration. This information will be verified by your provincial regulatory organisation. Applicants who are applying under Option B will need to arrange for verification of registration and good professional conduct to be sent to your provincial regulator. See Step 10 for more information. Have you ever been registered as a midwife? If yes, answer the questions below. (The Online Application will allow you to create multiple records in which you provide the following information for each place that you were registered.) Name of Regulatory Authority Date Registered Date Registration Ended Geographic area where registration is/was valid Country Briefly describe the process for gaining this registration If you wish to provide additional information about your registration(s) as a midwife you may do so here: September 2008 Page 8 of 28

9 Step Six: Midwifery Practice Sites Provide information about each place you have practised midwifery in your career. Start with your current or most recent midwifery experience. Do not include experience as a nurse or doctor. Be aware that you will need to provide evidence that you have the clinical experience needed to be eligible for MMBP. More information about this is available in Step Ten. If you have worked at the same site more than once, with a significant break in between, it should be listed twice. Short leaves at a site should be noted in the additional information section. # Practice Site Start Date End Date Additional Information: September 2008 Page 9 of 28

10 Please complete the following information for each practice site (the online application will allow you to create multiple records): Name of Practice Site: Start Date: End Date: Country: Type of Setting: (check all that apply) Home; Community Clinic; Free Standing Birth Centre; Birth Centre Attached to a Hospital; Hospital with no surgical or specialist care available; Hospital with surgical / anaesthesia / specialist capabilities but that are not always available; Hospital that is a referral center with full surgical, obstetrical and neonatal intensive care nursery available 24/7. Distance from nearest hospital with surgical capability: less than 5km; 5-15km; 16-30km; more than 30km What was your role at this site? (check all that apply) Primary Midwife Primary Role Start Date: Primary Role End Date: Other Midwife Other Midwife Start Date: Other Midwife End Date: Were you a student at this site? Yes No If yes, Start date of student placement: End date of student placement: September 2008 Page 10 of 28

11 Organisation of Work: (check all that apply) private practice employee student placement full-time part-time on-call shift work other: Describe your interactions with other healthcare providers: (provide information regarding consultation, discussions, transfers of care) Typical gestational age (in weeks) when your care began: Usual number of antenatal visits you had with a client: Total number of antenatal visits you attended in: and earlier Describe your role in providing antenatal care at this site: Typical point in labour at which your care began: early labour cm dilation/ contractions more than 5 min apart active labour 4-6cm dilated or greater/ contraction less than 5 min apart advanced labour - 7 cm or greater dilation second stage - 10cm, full dilation September 2008 Page 11 of 28

12 Describe your role in labour: Describe your role in birth: Number of births attended as Other Midwife: and earlier Number of births managed as Primary Midwife in a hospital setting: and earlier Number of births managed as Primary Midwife in an out-of-hospital setting: and earlier Usual number of postpartum visits you had with a client: September 2008 Page 12 of 28

13 Total number of initial newborn examinations you performed in: and earlier Total number of maternal postpartum visits you attended in: and earlier Total number of newborn visits you attended after the first 24 hours in: and earlier Typical point that your care ended: (in days, weeks, or months) Describe your role in providing maternal postpartum care: Describe your role in providing newborn care: September 2008 Page 13 of 28

14 Describe your role regarding family planning and contraceptives: Did you provide prenatal care through labour and birth and postpartum care to the same client? All of the time most of the time some of the time occasionally not at all Number of courses of care with continuity of care as defined by your provincial regulator: (definitions will be available in the Online Application) and earlier If you are applying to the Accelerated Option: Number of courses of care with continuity of care as defined by MMBP: (this definition will be available in the Online Application) and earlier September 2008 Page 14 of 28

15 Step Seven: Summary of Clinical Practice Answer the following questions in 300 words each or less. Include examples in your responses when possible. Describe your current practice. If you have no current practice, describe your most recent midwifery practice. Describe your communication style with the women in your care: Describe how decisions were made about care for the women in your practice: Explain what responsibility you had for women in your care: Explain in what circumstances other professionals might take responsibility: Describe how you have maintained your competence as a midwife: If you are involved in any professional midwifery or other related organisations, please describe your role: September 2008 Page 15 of 28

16 If you teach midwifery in any capacity, please provide a brief summary of your teaching career: Please describe any education, training or experience you have in health-related research and/or in the critical analysis of research literature: List your major strengths and major accomplishments as a midwife: Tell us what areas you hope to learn more about during the MMBP Pilot, to help you better practice midwifery in the Canadian context: Provide any additional information about your career as a midwife: September 2008 Page 16 of 28

17 Step Eight: English Language Fluency English is my: (choose one of the following) First language Second or additional language Name the language that you know best: Do you meet one of the MMBP criteria for exemption from English language testing? (See ) Exemption Criteria A Exemption Criteria B Exemption Criteria C None of the above I will be proving my English language fluency via an English language score test Complete only one of the following three options (based on your answer above). Exemption from English Testing (Criteria A) Canadian School Attended School name Start Date End Date Additional Information: September 2008 Page 17 of 28

18 Exemption from English Testing (Criteria B) Residence in an approved English Dominant Country Country Start Date End Date List only the MMBP-approved English dominant countries. Number of months of midwifery education in English: Country of midwifery education: Additional Information: Exemption from English Testing (Criteria C) Residence in an approved English Dominant Country Country Start Date End Date List only the MMBP-approved English dominant countries. September 2008 Page 18 of 28

19 Number of years of secondary-level education in English: Number of years of post secondary-level education in English: Attendance at English only secondary and post-secondary schools in English Dominant Countries School Name Country Additional Information: September 2008 Page 19 of 28

20 Step Nine: Additional Information Have you worked as a regulated health professional in Canada for at least 8 months of full-time practice within the last ten years? Yes No Have you passed a course about the Canadian healthcare system within the last five years that includes similar content to the MMBP approved course? Yes No Within the last five years, have you successfully completed a Canadian education program leading to a qualification in a regulated health profession in Canada? Yes No Describe any experience you may have in a different, but relevant occupation, such as obstetrical nursing or obstetrics: Are you planning to apply for the Accelerated Option by submitting an AO Portfolio in addition to your basic application? Yes No Provide any additional information you wish in support of your application: September 2008 Page 20 of 28

21 Step Ten: Evidence Required You must submit evidence that you meet the MMBP requirements. Before answering any questions about evidence, read the Information about MMBP Required Evidence. (See Required Evidence.pdf ) In the Online Application, you will list the documents ( evidence ) that your provincial regulatory organisation should expect to receive as part of your application. All evidence must have been requested by the time you finalize your application. *In the Online Application, you will see the table below and be able to add additional records until you have listed all documents that will be part of your application. Document # 1 Clinical Experience What will this document be proving? Description Request Date 2 Experience/Education in Canadian Health Care 3 Good Character/Identity 4 Good Character/Identity September 2008 Page 21 of 28

22 Complete the following information for each document listed in the table above: What will this document be proving? Name Change Clinical Experience English Language Fluency Experience/Education in Canadian healthcare Good Character and Identity Midwifery Education Professional Conduct Other: Document description: Form A1: Request for Midwifery Transcript, Form A2: Information about Midwifery Programs, Form A3: Request for Nursing Transcript, Form B: Proof of Professional Conduct, Form C1: Detailed Verification of Clinical Experience, Form C2: Applicant Declaration of Clinical Experience, Form C3: Employer Description of Typical Clinical Practice, Form D: Professional Reference Form, Form E: Translation Form Name Change Certificate Marriage Certificate WES Report Other: Document Format: Original document Notarized Copy Certified Translation Other Is it in English? Yes No Person or Organisation sending document: Date document requested: Notes: September 2008 Page 22 of 28

23 Step Eleven: Information for University of British Columbia The University of British Columbia (UBC) is creating and delivering the pilot course content for the intensives and distance-based midwifery courses. In order to tailor the pilot program appropriately, they request that you complete the questions in the next section. This information will be provided to UBC in an without anonymous format without your name attached to your responses. The information will not be accessible by your provincial regulatory assessors and will not be used in the assessment of your eligibility. The topics listed below are common weak areas for internationally-educated midwives coming to Canada. Please indicate your level of experience and competency in each of the following areas indicated below. Pick a number on the scale for each topic area and provide additional information in the text box below. Tell us about any specific areas under that topic in which you have a particular strength or weakness. Please see the Canadian Competencies for Midwives for a list of the entry-level competencies expected of Canadian midwives. Physical assessment of woman lympatics, thyroid, cardiac, pulmonary, nervous system: Notes: No education or experience Education but no experience Education and experience in supervised settings only Education and experience on my own responsibility Education and experience at an expert level History-taking: Notes: No education or experience Education but no experience Education and experience in supervised settings only Education and experience on my own responsibility Education and experience at an expert level September 2008 Page 23 of 28

24 Ordering and interpreting screening and diagnostic tests including the following: Routine prenatal blood work Ultrasound Urinalysis Vaginal and cervical cultures Notes: No education or experience Education but no experience Education and experience in supervised settings only Education and experience on my own responsibility Education and experience at an expert level Prescribing medical therapeutics in the course of routine and emergency obstetrical care, including: Uterotonics Antibiotics Antifungals Analgesics Anti-emetics Antihistamines Anaesthetics Notes: No education or experience Education but no experience Education and experience in supervised settings only Education and experience on my own responsibility Education and experience at an expert level Management of antepartum variations from normal: No education or experience Education but no experience Education and experience in supervised settings only Education and experience on my own responsibility Education and experience at an expert level September 2008 Page 24 of 28

25 Notes: Labour Management, including the following: In-hospital care Out of hospital care Vaginal examination during labour Induction of labour Labour dystocia Pain management non pharmacological Pain Management Narcotic and epidural analgesia Active management of third stage Spontaneous vaginal delivery without routine episiotomy Notes: No education or experience Education but no experience Education and experience in supervised settings only Education and experience on my own responsibility Education and experience at an expert level Emergency Skills including: Antepartum Hemorrhage, Postpartum Hemorrhage, Breech, Shoulder Dystocia, Prolapsed Cord, Twins, Non reassuring Fetal Status, Anaphylaxis No education or experience Education but no experience Education and experience in supervised settings only Education and experience on my own responsibility Education and experience at an expert level September 2008 Page 25 of 28

26 Notes: Newborn assessment, including the first 24 hours, ongoing growth and development up to 6 weeks: Notes: No education or experience Education but no experience Education and experience in supervised settings only Education and experience on my own responsibility Education and experience at an expert level Six-week postpartum care of woman and baby: Notes: No education or experience Education but no experience Education and experience in supervised settings only Education and experience on my own responsibility Education and experience at an expert level Speculum exam for purpose of PAP and cultures: No education or experience Education but no experience Education and experience in supervised settings only Education and experience on my own responsibility Education and experience at an expert level September 2008 Page 26 of 28

27 Notes: Bimanual examination: Notes: No education or experience Education but no experience Education and experience in supervised settings only Education and experience on my own responsibility Education and experience at an expert level IV canulation in hand and forearm: Notes: No education or experience Education but no experience Education and experience in supervised settings only Education and experience on my own responsibility Education and experience at an expert level Venipuncture: Notes: No education or experience Education but no experience Education and experience in supervised settings only Education and experience on my own responsibility Education and experience at an expert level September 2008 Page 27 of 28

28 Suturing 2nd degree perineal lacerations: Notes: No education or experience Education but no experience Education and experience in supervised settings only Education and experience on my own responsibility Education and experience at an expert level Comments about other specific competencies noted in the Canadian Competencies for Midwives : (See ) Other Information for UBC List the top three cities/towns, in the province you intend to practice, in which you would prefer to do your clinical placement if it is possible: Are there any special considerations or circumstances that UBC should be aware of? Do you have any special, skills that you would like UBC to be aware of? September 2008 Page 28 of 28

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