National College of Midwifery SIS and LMS Portal.Powered By Classe365

Preceptor Details

Today's Date^*

Profile Picture

Only used for a more personal connection and has no influence on acceptance as a preceptor.

Faculty Type^*

Note: For the purpose of this database entry, non-academic means clinical preceptor.

Preceptor Type^*

Legal First Name^*

Preferred First Name^*

Middle Name or Initial

Legal Last Name^*

Other Legal Names

Phone Number^*

Please input only numbers. (International numbers should include country code without parenthesis.)

Personal Email^*

Create Your NCM Email^*

NCM email addresses are first name, last initial, ##@midwiferycollege.edu (Examples: monicab34@midwiferycollege.edu, tyrong78@midwiferycollege.edu)

Please type your desired email address in full.

NCM reserves the right to change your desired email during the enrollment process.

Date of Birth^*

Only used for verification purposes. Use the calendar or type in your date of birth (MM-DD-YYYY). To use the calendar, double click on the month at the top to access your year, month and date of birth.

Preferred Pronouns

A preferred pronoun is a pronoun an individual chooses to identify with and would prefer others use when talking to or about that individual. It is the pronoun that a person uses for themself.

Mailing Address^*

Please provide the address at which you receive mail. This address is not necessarily the clinical practice address.

City^*

State^*

Zip Code^*

Country^*

Have you been a preceptor with NCM in the past?^*

What, if any, is the highest degree you earned at NCM?^*

What is the HIGHEST education you have completed?^*

Are you interested in enrolling in NCM's Bachelor of Science in Midwifery Program?^*

Please indicate if you have one of the following:^*

Please check the following to verify that you understand you will be required to complete Preceptor Orientation as the second step in this 3 step application process.^*

Orientation

Please check the following to verify that you understand that as faculty at a college you will be required to complete MEAC-Required Annual Training for Preceptors each year.^*

Annual Training

“Each one, teach one”

Certificate and License Information

Date of FIRST Midwifery or Medical Certificate/License Issued^*

Must be at least 3 years prior to today's date. If date is less than 3 years prior to today's date, please contact the office for instructions on proving you have done a minimum of 50 births as the primary attendant.

Use the calendar or type in the date (MM-DD-YYYY). To use the calendar, double click on the month at the top to access your year, month and date.

Clinical Site Name/DBA (if neither use First and Last Name)^*

If you are an ACADEMIC ONLY preceptor write that in this field please.

Approved Clinical Location^*

If your clinical location is not listed then NCM does not have permission to have students at this location at this time. Please contact NCM's president at president@midwiferycollege.edu to discuss updating this list.

Which of your CURRENT provider certificate or license will be the LAST TO EXPIRE?^*

NOTE: NCM only requires one Provider Certificate or License.

You will have the option to upload others in subsequent fields.

Expiration Date on the License or Certificate Listed Above.^*

Use the calendar or type in your date (MM-DD-YYYY). To use the calendar, double click on the month at the top to access your year, month and date.

Clinical Site

Student Information

ASM Students^*

Write the first and last name of each student followed by the word "current". If you are applying to be NCM faculty before you have a student relationship, put "applying" in this field.

If you are applying to be BSM faculty only, put "NA".

For example:
Natasha Hill current
Kiko Nako current

BSM Students^*

Write the first and last name of each student followed by the word "current". If you are applying to be NCM faculty before you have a student relationship, put "applying" in this field.

If you are applying to be ASM faculty only, put "NA".

For example:
Natasha Hill current
Kiko Nako current

Optional: Demographics (your answers do not affect your ability to become faculty, but help NCM secure funding)

Which categories describe you? Select all that apply to you: ^*

Native American or Alaska Native Asian African/Black Hispanic; Latinx; or Spanish origin Middle Eastern or North African Native Hawaiian or Other Pacific Islander White Some other race; ethnicity; or origin; I will specify more below. Prefer not to answer

If you chose above, "Native American" or "Some other race, ethnicity, or origin," please specify your tribal affiliation or race/ethnicity/origin here.

Current Employment Status^*

How many hours do you work for pay outside of your birth work and precepting work?

Other Responsibilities

In addition to being a preceptor for NCM, I also have significant care-giving responsibilities for someone living in my home (other than my own children).

Support

What is the most important support that you have had or are receiving currently?

Support from NCM

What type of support do you feel would be most helpful for you as a preceptor?

Challenges

What do you anticipate will be OR has been the most difficult personal challenge to precepting your student's NCM program of study?

Strengths

What has been your greatest personal strength in working with your student through their program of study?

The National College of Midwifery prohibits discrimination, harassment, retaliation, or discipline against any NCM community member or group including but not limited to the board of directors, volunteers, faculty, staff, contractors, prospective or current student on the basis of their actual, implied or perceived; because of race; color; national or ethnic origin or ancestry; religion or creed; age, sex, gender, gender identity or expression, including transgender identity; sexual orientation; marital status; familial status; age; ability/disability; genetic information; economic status, formal education, language, citizenship status, veteran status, genetic and/or ancestry information, political affiliation or other identities, including any other protected category under federal, state or local law. All personnel who are responsible for recruitment, admissions, hiring and promoting and for the development and implementation of college programs are entrusted to hold up this standard and to respond promptly and appropriately to any concerns that are brought to their attention.

Other Opportunities and Quality Improvement

Private CEU Teachers^*

Do you have a CEU course you are approved to teach and would like to offer it through our online learning platform? Do you have a specialty course that you would like to get approved for CEUs and offer it to midwives or midwifery students? La Plaza is the place to market your class and maximize capability, advertising, and enrollees!

Checking here and then clicking the submit button will constitute your electronic signature and certifies that all information is true and correct to the best of your knowledge.

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