MMBP Online Application Form Working Document September 2008

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© September 2008 Page 1 of 28

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

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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: Email Address:

Status in Canada: (choose one) Canadian Citizen; Permanent Resident; Work Permit;

Visitor Permit; Student Visa;

No Status at this time

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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:

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© September 2008 Page 4 of 28 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:

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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

www.cmrc-ccosf.ca/files/pdf/MMBP 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:

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© September 2008 Page 6 of 28 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:

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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

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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

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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

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© September 2008 Page 10 of 28 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:

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© September 2008 Page 11 of 28 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:

2008 2007 2006 2005 2004 2003 and

earlier

Describe your role in providing antenatal care at this site:

Typical point in labour at which your care began:

early labour - 0-3 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

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© September 2008 Page 12 of 28 Describe your role in labour:

Describe your role in birth:

Number of births attended as Other Midwife:

2008 2007 2006 2005 2004 2003 and

earlier

Number of births managed as Primary Midwife in a hospital setting:

2008 2007 2006 2005 2004 2003 and

earlier

Number of births managed as Primary Midwife in an out-of-hospital setting:

2008 2007 2006 2005 2004 2003 and

earlier

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© September 2008 Page 13 of 28 Total number of initial newborn examinations you performed in:

2008 2007 2006 2005 2004 2003 and

earlier

Total number of maternal postpartum visits you attended in:

2008 2007 2006 2005 2004 2003 and

earlier

Total number of newborn visits you attended after the first 24 hours in:

2008 2007 2006 2005 2004 2003 and

earlier

Typical point that your care ended: (in days, weeks, or months)

Describe your role in providing maternal postpartum care:

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© September 2008 Page 14 of 28 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)

2008 2007 2006 2005 2004 2003 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)

2008 2007 2006 2005 2004 2003 and

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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:

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© September 2008 Page 16 of 28 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:

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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 www.cmrc-ccosf.ca/node/209 )

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

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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

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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

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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

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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

www.cmrc-ccosf.ca/files/pdf/MMBP 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

# What will this document be proving? Description Request Date 1 Clinical Experience

2 Experience/Education in Canadian Health Care 3 Good Character/Identity

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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:

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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: 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

Notes:

History-taking:

No education or experience Education but no experience

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• Routine prenatal blood work • Ultrasound

• Urinalysis

• Vaginal and cervical cultures No education or experience Education but no experience

Notes:

Prescribing medical therapeutics in the course of routine and emergency obstetrical care, including: • Uterotonics • Antibiotics • Antifungals • Analgesics • Anti-emetics • Antihistamines • Anaesthetics No education or experience Education but no experience

Notes:

Management of antepartum variations from normal: No education or experience

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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 No education or experience

Notes:

Emergency Skills including:

• Antepartum Hemorrhage, Postpartum Hemorrhage, Breech, • Shoulder Dystocia,

• Prolapsed Cord, • Twins,

• Non reassuring Fetal Status, Anaphylaxis No education or experience

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Newborn assessment, including the first 24 hours, ongoing growth and development up to 6 weeks: No education or experience

Notes:

Six-week postpartum care of woman and baby: No education or experience

Notes:

Speculum exam for purpose of PAP and cultures: No education or experience

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Bimanual examination:

Notes:

IV canulation in hand and forearm: No education or experience Education but no experience

Notes:

Venipuncture:

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Notes:

Comments about other specific competencies noted in the Canadian Competencies for Midwives :

(See www.cmrc-ccosf.ca/files/pdf/National_Competencies_ENG.pdf )

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?