Preceptor Update Form

December 6, 2012

Name*
First Last
Email*
Practice Name*
I am able to take a midwifery student for the coming academic year (next September). Please inquire with the Program office if you need to know exact placement dates.*
Average number of births per month in your practice group:
Please enter a number from 0 to 100.
Annual Home Birth Rate (%):
Please enter a number from 0 to 100.
Practice Partners (Please list)
Hospital Privileges - hold ctrl (command for mac users) to select multiple choices. Please include pending applications.
If they have not changed please go to next question
Please refer to the Midwifery Program at UBC - Preceptor Agreement. A copy of this document can be found on our web site.
- I have read and agree to abide by the Midwifery Program Preceptor Agreement.
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