Form 08-4215c - Verification Of Supervised Clinical Experience Page 2
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2State of Alaska
Department of Community and Economic Development
Division of Occupational Licensing
Board of Certified Direct-Entry Midwives
P.O. Box 110806, Juneau, Alaska 99811-0806
(907) 465-2580
E-mail: license@dced.state.ak.us
VERIFICATION OF SUPERVISED CLINICAL EXPERIENCE
Births Attended:
Date of Birth,
S - Supervising Licensee (MD-CNM-CDM)
Location
Weight and Sex
P - Primarily Responsible for Labor & Delivery
A - Assisted with Labor Management
O - Observer
DOB
YES
S:
P:
Weight
A:
YES NO
Sex
O:
NO
Continuous Care Client
DOB
YES
S:
Weight
P:
A:
YES NO
Sex
NO
O:
Continuous Care Client
DOB
YES
S:
Weight
P:
A:
YES NO
Sex
NO
O:
Continuous Care Client
DOB
YES
S:
Weight
P:
A:
YES NO
Sex
NO
O:
Continuous Care Client
DOB
YES
S:
P:
Weight
A:
YES NO
Sex
NO
O:
Continuous Care Client
DOB
YES
S:
Weight
P:
A:
YES NO
Sex
NO
O:
Continuous Care Client
CONTINUOUS CARE CLIENTS. As part of the supervised clinical experiences required, an applicant must have provided
continuous care to at least 15 clients. "Continuous care" means, for the same client, the applicant
1. performed at least six prenatal visits;
2. observed, assisted with, or had primary responsibility for labor and delivery of the newborn and placenta;
3. performed a newborn examination; and
4. performed a postpartum examination of the mother.
I declare the above information is true and correct to the best of my knowledge. I also understand that if I falsify any information,
I may forfeit the opportunity to be certified in the State of Alaska.
Applicant's Signature:
Date:
08-4215c (Rev. 11/99)
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