Form 08-4215c - Verification Of Supervised Clinical Experience
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1
2State of Alaska
Department of Community and Economic Development
Division of Occupational Licensing
333 Willoughby Avenue, 9th Floor, State Office Building
P.O. Box 110806, Juneau, AK 99811-0806
(907) 465-2580
E-mail: license@dced.state.ak.us
VERIFICATION OF SUPERVISED CLINICAL EXPERIENCE
Applicants must verify clinical experience under the experience supervision of a preceptor who meets the qualifications
of 12 AAC 14.210.
I,
, certify that
Name of Preceptor
Name of Applicant
obtained clinical experience under my preceptorship, which included the following number of experiences (as documented
on the following pages of form 08-4215c):
Number of prenatal visits (100 required for certification).
Number of labor and delivery observations (10 required for certification).
Number of assisted labor managements (20 required for certification).
Number of labors and deliveries of the newborn and placenta in which the applicant was the primary
responsible person (30 required for certification).
Number of newborn examinations (30 required for certification).
Number of postpartum examinations of the mother (30 required for certification).
Documentation of clinical experience on enclosed forms should include:
1. Date of birth.
2. Location of birth.
3. Infant's gender.
4. Infant's weight.
5. Name of person who assisted at the birth (A = Assistant).
6. Name of person who delivered the newborn and placenta (P = Primary Midwife).
7. Number of prenatal and postpartum visits applicant participated in on each client.
8. Any complication and its outcome. (Please attach separate piece of paper.)
9. A detailed explanation of any situation that required emergency transport. (Please attach separate piece of paper.)
To be completed by person verifying experience.
I certify that all information provided on this form is true and correct and that the care provided was within the scope of
AS 08.65 and 12 AAC Chapter 14.
Signature of Preceptor
Date
NOTARY SEAL
Type of License
License No.
State of Licensure
Original Issue Date
Expiration Date
SUBSCRIBED AND SWORN TO before me, a notary public, in and for the state of
this
day of
, 19
.
Notary Public
08-4215c (Rev. 11/99)
My Commission Expires:
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