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Midwifery Program | Department of Family Practice
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Faculty of Medicine
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2022
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March
»
08
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Preceptor Application
Preceptor Application
March 8, 2022
Please complete the following:
Name
*
First
Last
Email
*
Midwife Registration Number
*
Phone
*
Hospital Privileges - hold ctrl (command for mac users) to select multiple choices. Please include pending applications.
Abbotsford Regional Hospital & Cancer Centre
Burnaby Hospital
Campbell River & District General Hospital
Children's & Women's Health Centre of BC
Chilliwack General Hospital
Cowichan District Hospital
Creston Valley Hospital
East Kootenay Regional Hospital
Elk Valley Hospital
GR Baker Memorial Hospital
Kelowna General Hospital
Lady Minto Gulf Islands Hospital
Langley Memorial Hospital
Lion's Gate Hospital
Nanaimo Regional General Hospital
Peace Arch District Hospital
Penticton Regional Hospital
Richmond General Hospital
Ridge Meadows Hospital
Royal Columbian Hospital
Kootenay Boundary Regional Hospital
Kootenay Lake Hospital
Queen Victoria Hospital
Royal Inland Hospital
Shuswap Lake General Hospital
Squamish General Hospital
St. Joseph's General Hospital
St. Mary's Hospital
St. Paul's Hospital
Surrey Memorial Hospital
University Hospital of Northern British Columbia
Victoria General Hospital
Vernon Jubilee Hospital
West Coast General Hospital
Wrinch Memorial Hospital
Practice Information
Practice Name
*
Is this a newly established practice or has the practice moved in the past year? If not proceed to the section: PRACTICE INFORMATION
*
No
Yes
Third Choice
New Practice Address
Street Address
Address Line 2
City
Postal Code
Practice Phone
Practice Website
Practice Email
Practice Coordinator
First
Last
Practice Partners (list names)
Practice Model
Solo
Group/Shared Care
Group/Primary Care
Interdisciplinary
Average number of births per month (in call group where applicable)
*
Please enter a number from
0
to
100
.
Annual Home Birth Rate (%)
*
Please enter a number from
0
to
100
.
Special populations served by your practice
First Nations/Inuit
LGBQTTI
Chemical Dependency
Mental Health
Low Income/New Canadians
Other - please specify
Other populations
Describe specialized learning opportunities available at your practice
Lactation Consulting
Homeopathy/Herbal Medicine
Naturopathy
Accupuncture
Traditional Chinese Medicine
Group Care
Other - please specify below
Other learning opportunities
Precepting Experience
Years of Practice as a Midwife
*
Please enter a number from
0
to
100
.
UBC Preceptor Workshops Attended (list)
*
Other Preceptor Workshops Attended (non-UBC) (please list)
List your precepting experience
*
I have never been a preceptor
Midwifery Student
IMPP/MMBP/Conditional
Nursing student
Medical Student
Other - Please specify below
Other precepting experience
Precepting Experience Detail
If applicable, please provide more detail on the extent and type of your experience supervising students.
Approximate # of students precepted
0
1-3
4-8
>8
Do you have a clinical faculty appointment with UBC
*
No
Yes
Please share any additional skills or experience you have:
I am interested in precepting a UBC Midwifery student in the coming academic year (starting September). Please specify. Please contact the Midwifery Program office if you need to know exact term dates. :
Terms 1 & 2: Sept - April
Term 1 only: Sept - November
Term 2 only: Jan - April
I am interested, but not available this year
Δ
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