Licensed Midwife Renewal/Reinstatement Application

Transcription

1 Vermont Secretary of State Attn: Renewal Clerk Office of Professional Regulation 89 Main St. 3 rd Floor Montpelier, VT Licensed Midwife Renewal/Reinstatement Application Renewal Clerk (802) Current Expiration 01/31/2015 You Must Complete The Information Below: Renewal Period Covering 02/01/2015 through 01/31/2017 Renewal Application Fee $ [n Refundable Processing Fee] Checks Payable to: Vermont Secretary of State For Office Use Only License #: ---- Name: Address: City/State/ZIP: Country: Directions: To renew you must enclose a check or money order in the amount indicated, payable in US funds from a bank with a United States affiliate to Vermont Secretary of State. The renewal fee is non-refundable. If the completed renewal application, along with all supporting documentation, is not received in the Office by the expiration date, you will be required to pay an additional penalty in addition to the renewal fee. Call the Office for a calculation of the penalty before submitting this renewal application. Reminder: You may not practice your licensed profession without an active license. Faxes not accepted. Has your name changed since you last renewed, or were originally licensed? (Circle One) If, you must attach a copy of your marriage license, civil union license or section of divorce decree granting you the authority to change your name. Section A: Demographic Information If your mailing address has changed, indicate your new address in the box to the right. te: It is unprofessional conduct for a licensee to fail to notify the Secretary of State s Office of a change of name or address within thirty (30) days (3 V.S.A. 129a(a)(14)). P.O. Box Street/Apt # City/State/Zip Country Street/Apt # If your 911 address has changed, indicate your new address in the box to the right. Suite/Department/Floor City/State/Zip Phone: ( ) - Cell Phone: ( ) - Address: Date of Birth (MM/DD/YYYY) Gender: (Circle One) DEA # / / Male Female

2 Section B: Vermont Mandatory Good Standing Declarations CHILD SUPPORT: Child Support Orders, 15 V.S.A. 795(b): Good standing for child support is defined by 15 V.S.A. 795(d). You must check the appropriate box. As of the date of this application: I am not subject to a child support order. I am subject to a child support order and I am in good standing or in full compliance with a plan to pay any and all child support. I am subject to a child support order and I am NOT in good standing or in full compliance with a plan to pay any and all child support. Please contact the Office of Child Support at (802) OCS must report your compliance to this office before you may be issued a license. TAXES: Taxes Due to the State of Vermont, 32 V.S.A. 3113(b): Good Standing for taxes due is defined by 32 V.S.A. 3113(g). You must check the appropriate box. As of the date of this application: I am in good standing with respect to, or in full compliance with a plan to pay any and all taxes due to the Vermont Department of Taxes. I am NOT in good standing * with respect to or in full compliance with a plan to pay any and all taxes due to the Vermont Department of Taxes. Please contact the Vermont Department of Taxes at (802) for more information. The Tax Department must report your compliance to this office before you may be issued a license. DISTRICT COURT FINES/JUDICIAL BUREAU: Court judgments for fines or penalties, 4 V.S.A. 1110(b): Good standing for court judgments is defined by 4 V.S.A. 1110(c). You must check the appropriate box. As of the date of this application: I have no unpaid judgments issued by the judicial bureau or criminal division of the superior court for fines or penalties for a violation or criminal offense. I am in good standing with respect to any unpaid judgment issued by the judicial bureau or criminal division of the superior court for fines or penalties for a violation or criminal offense. I am NOT in good standing with respect to any unpaid judgment issued by the judicial bureau or criminal division of the superior court for fines or penalties for a violation or criminal offense. You must provide this office documentation of compliance before you may be issued a license. RESTITUTION ORDERS: Unpaid Judgments, 13 V.S.A. 7043a: Good standing for restitution orders is defined by 13 V.S.A. 7043a(c). You must check the appropriate box. As of the date of this application: I have no restitution order. I am in good standing with respect to any restitution order. I am NOT in good standing with respect to any restitution order. You must provide this office documentation of compliance before you may be issued a license. Name (print): License Number: 2

3 Section C: Vermont Mandatory Credential and Fitness Questions Please circle or for each of these questions. If the answer is, follow the provided instructions. Since your license was last renewed (or since it was issued if within the last two years): Has Vermont or any other state, federal authority, or any jurisdiction (US or elsewhere) denied an application by you for a license, certificate, or registration to practice a profession or occupation? If, you must attach a copy of the order or official notification of the action(s). Since your license was last renewed (or since it was issued if within the last two years): Has Vermont or any other state, federal authority, or any jurisdiction (US or elsewhere) taken any disciplinary action (restricted, suspended, revocation or conditioned) against a license, certificate, or registration that you hold or held in any profession or occupation? If, you must provide a copy of the order or official notification of the action. Since your license was last renewed (or since it was issued if within the last two years): Have you surrendered a license, certificate, or registration to a licensing authority in Vermont or any other state, federal authority or other jurisdiction (US or elsewhere)? If, you must provide a detailed written explanation and copies of any applicable documentation. Are you currently under investigation by a licensing authority in Vermont or any other state, federal authority or other jurisdiction (US or elsewhere)? If, you must provide a detailed written explanation and a copy of any available information from the licensing authority. Since your license was last renewed (or since it was issued if within the last two years): Have you been convicted of a crime other than a minor traffic violation? Driving While Intoxicated and Driving Under the Influence are not minor traffic violations. If, you must provide a detailed written explanation and attach the official court documents, (i.e., the affidavit of probable cause, the information and/or the docket report). Do you have any criminal charges pending against you in Vermont or any other jurisdiction (US or elsewhere)? If, you must provide a detailed written explanation and attach a copy of the charging documents. Vermont law requires that you report to the Office of Professional Regulation a felony conviction or any conviction of a crime related to the practice of your profession within 30 days. 3 V.S.A. 129a(a)(11). The answers to the following questions are not subject to public disclosure: Do you have a physical or mental condition or disorder which in any way impairs or limits your ability to practice this profession with reasonable skill and safety? If, you must have your health care provider submit a detailed statement explaining how you are able to practice safely. Does your use of alcohol, substances, or prescription medications impair or limit your ability to practice this profession with reasonable skill and safety? If, you must provide a detailed written explanation. Are you currently addicted to or in any way dependent on alcohol or habit forming drugs? If, you must provide a detailed written explanation. Name (print): License Number: 3

4 Section D: Continuing Education Requirement You are not required to send any supporting documentation with this form if you renew by the license expiration date. The Office of Professional Regulation reserves the right to verify information submitted by applicants for renewal and conducts a random audit of CE for each profession. You must retain all documentation for seven years after completion of the program/course. Please complete the Continuing Education Record on the next page. If you are renewing more than 30 days late, you must submit all CE documents with your completed renewal form. Midwifery Administrative Rule 3.3 Continuing Education Requirements All midwives licensed and residing in this state must complete a minimum of 20 hours of continuing education during the two-year renewal period and must so certify at the time of license renewal. The continuing education requirement does not apply for the renewal period during which a midwife initially obtained licensure. It will begin with the first full two-year renewal period. Continuing Education Requirement (Check the box that applies to your license.) My Midwife license was first issued in Vermont on or after 02/01/2013; therefore I do not have to complete Continuing Education for this renewal cycle (0 hours). My Midwife license was first issued in Vermont prior to 02/01/2013; and I have completed 20 hours of continuing education. I have NOT met the continuing education requirement (CE extensions may be granted in exceptional circumstances for good cause shown upon written request with a completed renewal form and fee submitted prior to the expiration date.) Name (print): License Number: 4

5 Itemize the education courses taken over the past two years (submit additional sheets if more space is needed) TITLE & CONTENT OF PROGRAM SPONSORING ORGANIZATION # OF CREDITS/HOURS AWARDED DATES TOTAL # OF CREDITS/HOURS: Name (print): License Number: 5

6 Section E: Peer Reviews Midwifery Administrative Rule, 3.8 Peer Reviews A midwife licensed in this state must participate in at least four separate peer review meetings evaluating the Midwife s practice during each two-year renewal period as a condition of license renewal. Have you submitted at least four (4) peer reviews that took place between February 1, 2013 and January 31, 2015? Section F: Practice Data Midwifery Administrative Rule 3.9 Individual Practice Data As a condition of license renewal, a midwife licensed in this state must submit to the Office individual practice data information covering each two-year renewal period. Such individual practice data must include information about each home birth attended during the renewal period. Have you submitted data to the database maintained by the Division of Research of the Midwives Alliance of rth America for each birth at which you were the attending midwife? Section G: Cardiopulmonary Resuscitation (CPR) Certification Midwifery Administrative Rule 3.10 CPR Certification A midwife licensed in this state must show proof of current cardiopulmonary resuscitation certification for adults and newborns and for neonatal resuscitation as a condition of initial issuance of license and of license renewal. Have you submitted proof of current Cardiopulmonary Resuscitation (CPR) Certification? Section H: Consultation for Emergency Transfer and Transport Midwifery Administrative Rule 3.14 Written Plan for Consultations and for Emergency Transfer and Transport. Each licensed midwife must develop a written plan (1) for consultation with physicians (MD or DO) and other health care providers and (2) for emergency transfer and for transport of an infant or a client, or both, to an appropriate health care facility. The written plan must be submitted to the Director on an approved form with the initial license application and with every subsequent license renewal. Have you submitted your current plan for consultation, emergency transfer and transport? Name (print): License Number: 6

7 Section I: Birth Certificate 26 V.S.A Renewals (E) Filed a timely certificate of birth for each birth at which he or she was the attending midwife, as required by law. Have you filed a timely birth certificate for each birth at which you were the attending midwife? Section J: Expired Renewal If this is a late renewal, have you been practicing in Vermont since your license expired? If, please attach a description of the extent of your practice since your license expired. N/A Section K: Affirmation Statement of Applicant I certify, under the pains and penalties of perjury, that all information I have provided in this application is true and accurate. I understand that furnishing false information may constitute unprofessional conduct and result in the denial of my application for renewal or further disciplinary action. The maximum penalty for perjury is fifteen years in prison and/or a $10,000 fine. (13 V.S.A. 2901) Signature of Applicant **(REQUIRED)** Signature Date (MM/DD/YYYY) Print Name: License # ---- Name (print): License Number: 7

8 Office of Professional Regulation Licensed Midwife National Life Building, rth, Floor 2 Montpelier, VT Phone: (802) Fax: (802) Vermont Office of Professional Regulation Survey (optional) 2015 Renewal License #: Name: Would you be willing to serve as a Board/Advisor member of the Board/Commission/Advisory panel for your profession? If you answer "," submit a letter of intent and resume to the Office for consideration. 2. Would you be willing to serve as an Ad Hoc member of the Board/Commission/Advisory panel for your profession? If you answer "," submit a letter of intent and resume to the Office for consideration. 3. Would you be willing to serve as an Expert Witness for a licensing case(s) associated with your profession? If you answered to the question above, what is your area of expertise? Name (print): License Number: 8

9 Vermont Secretary of State Attn: Renewal Clerk Office of Professional Regulation 89 Main St. 3 rd Floor Montpelier, VT (This report must be typed) Report of Peer Review Renewal Clerk (802) Date Midwife Full Name License # Each Peer review must be conducted with at least two other licensed midwives who have no personal, professional or financial interest in the birth being reviewed. 1 st Reviewer s full name: License# nd Reviewer s full name: License# 107- REASON FOR REVIEW: Is this review for a transport (circle one)? Hospital of transport: Reason for transport: Any infant or maternal mortality or significant morbidity (circle one)? If, explain: Name (print): License Number: 9

10 Date of Delivery: LMP EDD Wks gestation PRENATAL HISTORY: (Age, gravity, parity, notable medical abnormal labs, etc.) LABOR AND BIRTH SUMMARY: BIRTH NARATIVE: (What happened, how the midwife responded, outcomes) Name (print): License Number: 10

11 Chronology Date Time EDD N/A Labor onset Active labor Full dilation Delivery ROM 5 min APGAR DISCUSSION: (Group interaction and input, questions, clarifications) CONCLUSIONS/RECOMMENDATIONS: (What was learned from the review, practice or protocol changes?) STATEMENT OF REVIEWER All of the statements made written in this review are a true and accurate accounting of the proceedings of the peer review session, to the best of my knowledge. Signature of Reviewer Date Name (print): License Number: 11

12 Vermont Secretary of State Attn: Renewal Clerk Office of Professional Regulation 89 Main St. 3 rd Floor Montpelier, VT Renewal Clerk (802) CURRENT PLAN FOR CONSULTATION, EMERGENCY TRANSFER AND TRANSPORT Renewals must comply with Rule 3.14 of the Administrative Rules for Midwives. The licensed midwife recognizes that there are certain conditions when medical consultations or transfers, or both are advisable. Each licensed midwife must develop a written plan (1) for consultation with physicians (M.D. or D.O.) and other health care providers and (2) for emergency transfer and transport of an infant or a client, or both, to an appropriate health care facility. The written plan must be submitted to the Director on an approved form with the initial license application and with every subsequent license renewal. Date Midwife Full Name License # 1. The licensed physician(s)(md or DO) who is/are engaged in active clinical obstetrical practice and with whom I will consult when there are significant deviations from the normal in either the mother or the infant is: (If more than three consultants, please attach additional sheets.) Name: Address: City/State/Zip/Phone: Name: Address: City/State/Zip/Phone: Name: Address: City/State/Zip/Phone: Name (print): License Number: 12

13 2. In an emergency transport to a hospital the following are available: CALL 911 PRIVATE TRANSPORTATION PROVIDER S CAR AMBULANCE 3. In the event of a maternal emergency in an out-of-hospital setting, I will transport to the following hospital(s): Hospital Name: Address: City/State/Zip/Phone: Hospital Name: Address: City/State/Zip/Phone: Name (print): License Number: 13

14 4. In the event of a neonatal emergency in an out-of-hospital setting, I will transport to the following hospital(s): Hospital Name: Address: City/State/Zip/Phone: Hospital Name: Address: City/State/Zip/Phone: STATEMENT OF MIDWIFE I certify that all information I have provided is true and accurate to the best of my knowledge. Should I furnish any false information on this plan, I hereby understand that such an act shall constitute cause for disciplinary action against my license as a Midwife. Signature of Midwife Date Name (print): License Number: 14

15 Vermont Dept. of Health 2014 Census of Licensed Midwives Vermont Midwife License Number: First Name: Last Name: Are you Hispanic, Latino/a, or of Spanish origin? (check all that apply) ( ) ( ), Mexican, Mexican American, Chicano ( ), Puerto Rican ( ), Cuban ( ) Other Hispanic, Latino, or Spanish origin ( ) Prefer not to answer Race? (check all that apply) ( ) American Indian or Alaska Native ( ) Asian ( ) Black or African American ( ) Native Hawaiian or Pacific Islander ( ) White ( ) Other (please specify): ( ) Prefer not to answer Education What is your highest earned educational degree? ( ) High school/ged ( ) Associate s Degree (AA, AS, etc) ( ) Bachelor s Degree (BA, BS, etc) ( ) Master's Degree (MA, MS, MSW, etc) ( ) Doctoral Degree (e.g. PhD, EdD) ( ) Other (please specify) In what year did you complete your highest earned degree? Where did you complete your highest earned degree? State/Province (postal abbreviation) If completed outside the U.S. or Canada, please specify country: License & Practice For how many years have you provided direct client care as a licensed midwife (in any state)? In what state(s) do you hold an active midwife license? State (postal abbreviation(s)) Do you maintain any other license(s), besides your midwife license, such as nurse, physical therapist, etc? ( ) ( ) If yes, please specify: What is your employment status? (select all that apply) ( ) Actively working in a position that requires a midwife license ( ) Actively working in a position that does not require a midwife license ( ) Actively working in a field other than midwifery ( ) t currently working ( ) Retired Do you have a National Provider Identification (NPI) number? ( ) ( ) If yes, please enter it here: Do you provide direct client/patient care in Vermont as a midwife? ( ) ( ) If no, do you plan to start (or resume) direct client care in Vermont as a licensed midwife within the next 12 months? ( ) ( ) * If not providing direct client/patient care in Vermont, stop here. Thank you. page 1 of 3

16 For how many years have you provided direct client/patient care in Vermont as a licensed midwife? What are your plans for the next 12 months regarding direct client care in Vermont? ( ) Increase hours ( ) Retire ( ) Decrease hours ( ) Continue as you are ( ) Seek non-clinical job ( ) Unknown Please answer the following questions regarding your primary Vermont practice: Where your worksite (e.g., birth center), or office (if attending home births), is based: Vermont town Practice Name Street address of work or office site (not a mailing address): ZIP code of office site location: Which best describes the type of setting that most closely describes this practice: (select one) ( ) Home birth practice ( ) Birth Center ( ) Hospital ( ) Other setting (please specify): How far (in terms of driving time) do you travel from your office location to attend home births (if any)? In the past year, during how many weeks did you work at this practice as a midwife? (48 weeks is considered "year round") Please indicate the average number of hours spent per working week (excluding on-call hours) in this practice on direct client/patient care/healthcare services: Please indicate the average number of hours per working week you spend in this practice on each of the following activities that are not direct client care: Administration Supervision Other activities: Teaching Research Do you accept new patients in this practice? ( ) ( ) Do you participate in Medicaid in this practice? ( ) ( ) Do you accept new Medicaid patients in this practice? ( ) ( ) Do you have a second practice or office site in Vermont? ( ) ( ) If you do not have a second practice or worksite in Vermont, stop here. page 2 of 3

17 Please answer the following questions regarding your secondary Vermont practice, if any: Where your worksite (e.g., birth center), or office (if attending home births), is based: Vermont town Practice Name Street address of work or office site (not a mailing address): ZIP code of office site location: Which best describes the type of setting that most closely describes this practice: (select one) ( ) Home birth practice ( ) Birth Center ( ) Hospital ( ) Other setting (please specify): How far (in terms of driving time) do you travel from your office location to attend home births (if any)? In the past year, during how many weeks did you work at this practice as a midwife? (48 weeks is considered "year round") Please indicate the average number of hours spent per working week (excluding on-call hours) in this practice on direct client/patient care/healthcare services: Please indicate the average number of hours per working week you spend in this practice on each of the following activities that are not direct client care: Administration Supervision Other activities Teaching Research Do you accept new patients in this practice? ( ) ( ) Do you participate in Medicaid in this practice? ( ) ( ) Do you accept new Medicaid patients in this practice? ( ) ( ) Do you have additional practices in Vermont? ( ) ( ) If yes, please describe them briefly in the space below. Thank you! page 3 of 3