Aviva Institute
Approved Preceptor Agreement

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This agreement is between hereafter known as preceptor, and Aviva Institute. This is a statement of intention to accept midwifery students from Aviva Institute.   Which students are selected are entirely the decision of the preceptor, using whatever criteria normally used to select students such as practice style and availability. This agreement is not intended as an exclusive agreement and preceptors are free to accept students from other programs.


The preceptor has met the following qualifications:
Be a CPM, CNM, ND, NP, MD, DC, or other licensed or certified health care provider.
Exceptions made on a case by case basis with prior approval.
Have more than five years experience in the area you are certified/licensed in.
For those with out-of-hospital birth practices, be able to offer specific experience such as GYN or prenatal, venipuncture, vitals, general health care, etc.


The preceptor agrees to fax (800) 584-6235 or scan email as jpg or pdf files the following:

1.      Copies of professional licenses or certification relevant to the area being taught.

2.      Copies of current CPR or Neonatal Resuscitation Cards/

3.      Copies of drivers license or other ID.

4.      Email or fax this signed agreement

5.      When you are placed with a student to receive payment we need:

a.       W9 form for payments as a independent contractors. Located at http://www.irs.gov/pub/irs-pdf/fw9.pdf

b.      Copies of a business card or practice brochure.


The preceptor agrees to the following responsibilities: (Please initial each box to show your agreement)
Have a written agreement with each student, clearly outlining her responsibilities and your expectations.
Carry malpractice insurance, or have an informed consent form that all your clients sign, which states that you do not carry malpractice insurance, and which legally waives the school's liability for you and your student.
Provide a physical location and adequate clinical space; provide or help to arrange a variety of client encounters.
Provide the opportunity for the student to perform clinical activities. Be available for supervision, consultation and teaching.
Supervise, demonstrate, teach, and observe the student in clinical activities, in order to develop her skills and to ensure proper care of the client.
Delegate gradually increasing levels of responsibility to the student as her skills develop.
Schedule regular time to review objectives with the student in order to identify problem areas, and provide specific experiences in order for her to resolve these.
Allow the student to utilize documentation skills appropriate to midwifery management.
Participate in the evaluation of the student's clinical skills and theoretical knowledge base through the following mechanisms:
  1. Direct supervision, observation and teaching in the clinical setting.
  2. Encourage and support students? oral presentations.
  3. Complete regular written evaluations for the purpose of monitoring  by the student and program.
  4. Support the student in completing birth reports and other necessary school records.  Verify with signature and comments.
  5. Facilitate relations between the student and other  professionals in the setting/community.
  6. Participate in preceptor training as provided by Aviva Institute or others.
  7. Provide early notification if problems arise that would prevent the preceptor from accomplishing the above items or diminish the training experience for the student.


Aviva Institute agrees to the following:

1.      To provide training resources in clinical teaching.

2.      To provide guidelines on written agreements for student and preceptors outlining responsibilities, length of training etc.

3.      To provide needed forms for evaluation both about the student and from the student about your practice.

4.      To provide links and other marketing listing the preceptors practice

5.      Discounts in continuing education courses offered by Aviva.

6.      Set regular meetings between the preceptors and administration to check in on student progress and provide assistance as needs.

7.      Assist in resolving any problems or issues that may arise.

8.      To pay a stipend to cover the preceptor time in administration. This stipend is currently $20.00 per academic credit. A total of 68 credits are required, if a preceptor filled all of the students clinical requirements, the stipend would total $1,340.00

9.      If the preceptor charges an additional fee, such as high volume practices, Aviva will collect that fee from the students and passing it directly on to the preceptor, minus a 5% processing fee to cover credit card fees, and administrative time. The student may also pay the preceptor directly.




Preceptor
Date
I agree typing my name and submitting this form that this constitutes my legal signature and this document can be used as a legal and binding document.