N.H. Admin. Code § Mid 302.03

Current through Register No. 45, November 7, 2024

Section Mid 302.03 - Application Form for Initial Certification

On the 2-part application form the applicant shall furnish:

(a) On the publicly available part of the form:

(1) The applicant's name and any names previously used;

(2) The date of the application;

(3) The applicant's date of birth;

(4) The applicant's work address;

(5) The applicant's work numbers, including, as applicable, the applicant's office telephone number, cell phone number and fax number;

(6) The applicant's business e-mail address, if applicable;

(7) In the space provided, a statement by the applicant expressing intent to engage in the practice of midwifery in the state;

(8) The name and address of the high school attended by the applicant and the date of graduation, or the date of completion of high school equivalent;

(9) If applicable, a list of colleges and universities the applicant attended, the dates of attendance, and the degrees received;

(10) A written description of any part of the applicant's professional background which is relevant to the practice of midwifery, such as:

a. Midwifery training or experience in any state or country; or

b. Any training or experience in the fields of newborn or maternal care, acquired in any state or country, such as emergency technician, obstetric or pediatric nursing, childbirth education or work as a doula;

(11) A list of midwifery schools attended and, for each such school:

a. The dates attended;

b. The date of graduation; and

c. The degree, certificate, or diploma awarded;

(12) A list of midwifery certifications, licenses, registrations or other permits to practice midwifery held by the applicant currently or in the past, including for each such permit:

a. The state, country, or organization of issuance; and

b. The dates of issuance and expiration;

(13) A list of all certifications, licenses, registrations, or other permits to practice in a health or healing field other than midwifery, including for each such permit:

a. The state or country of issuance; and

b. The dates of issuance and expiration;

(14) A statement describing the circumstances of any conviction of a crime disclosed by any affidavit required to be submitted by Mid 302.05(h);

(15) A statement describing the arrangements the applicant has made for the medical back-up as required by Mid 303.01(h), including in the description:

a. Arrangements for coverage for clients in the event of the applicant's absence or illness;

b. Arrangements for consultation with obstetricians, family practitioners, pediatricians or any other physicians concerning abnormal conditions;

c. Arrangements for transferring the care of clients from the midwife to obstetricians, family practitioners, pediatricians or any other physicians;

d. Identification of privileges at hospitals; and

e. Identification of hospital services to be used in medical emergencies;

(16) A statement describing the applicant's arrangements for:

a. Laboratory testing;

b. Newborn screening; and

c. Obtaining medications permitted by law;

(17) The applicant's signature to a statement preprinted on the form which states that:

a. The information provided on the application form and the documentation provided to support the application are true, accurate, complete and unaltered; and

b. The applicant acknowledges that, pursuant to RSA 641:3, the knowing making of a false statement on the application form is punishable as a misdemeanor; and

(18) The date of the signature;

(b) On the confidential part of the form:

(1) The applicant's name;

(2) The applicant's home address and home telephone number;

(3) The applicant's home e-mail address, if he or she chooses to provide it;

(4) Disclosure of the following information, the relative seriousness of which shall be used to evaluate the fitness of the applicant to practice midwifery pursuant to Mid 303.01(g):

a. Whether a malpractice claim has been made against the applicant within the last 6 years, regardless of whether a lawsuit was filed in relation to the claim;

b. Whether the applicant has ever been denied a midwifery certificate, license, registration or permit to practice midwifery for any reason;

c. Whether the applicant's employment or appointment in a hospital, clinic or other health care facility was ever suspended;

d. Whether the applicant has ever resigned from employment or appointment in a hospital, clinic or other health care facility in lieu of being subjected to disciplinary action;

e. Whether there are pending against the applicant any disciplinary charges before any licensing authority, medical council, health care facility or professional midwifery association;

f. Whether any disciplinary action has been taken against the applicant by any licensing authority, medical council, health care facility or professional midwifery association;

g. Whether the applicant has ever voluntarily surrendered a certificate, license, registration or permit to practice midwifery or other healing art in lieu of facing disciplinary action;

h. Whether the applicant has ever had a professional certificate, license, registration or permit to practice in a field other than midwifery revoked, suspended, or otherwise terminated on disciplinary grounds; and

i. Whether the applicant currently has an emotional disturbance or mental illness, a physical illness, or an addictive disorder impairing the applicant's ability to practice midwifery;

(5) A statement describing in detail the circumstances of any affirmative answers to the questions listed; and

(6) The applicant's social security number provided in the space below the following preprinted notice:

"The Midwifery Council will deny certification if you refuse to submit your social security number (SSN). Your professional certificate will not display your SSN. Your SSN will not be made available to the public.

The Midwifery Council is required to obtain your social security number for the purpose of child support enforcement in compliance with 42 USC 666(a)(13) and RSA 161-B:11. This collection of your social security number is mandatory."; and

(c) If the applicant so chooses, the information requested on the attached "Optional Informational Question", effective August 2018.

N.H. Admin. Code § Mid 302.03

#7421, eff 1-3-01, EXPIRED: 1-3-09

New. #9691, eff 4-8-10

Amended by Volume XXXVIII Number 50, Filed December 13, 2018, Proposed by #12660, Effective 11/5/2018, Expires 11/5/2028.