APPLICATION FOR RENEWAL OF CERTIFICATION OF
Contents
1. DATA Standards 16 0 18 0 A Do you keep an annual tally of responses of the evalua tions by clients of their teacher and follow up sessions Standard 16 2 1 Include tallies for each Yes No Do you review on a follow up by follow up basis satis faction and confidence responses of new clients taught Standard 17 2 1 Include completed Attachment 3 Yes No Do you keep statistics for your service program including the number of follow ups pregnancy evaluations demogra phic data client population etc as prescribed by Creighton Model Standard 18 0 Include copies of log census report forms etc Yes No VII REFERRALS Standard 19 0 Do you maintain a list of the resources you utilize for all areas of referral Please include your list of referrals Yes No VIII CONTINUING EDUCATION Standard 20 0 A Please indicate continuing education programs attended or studies completed WITHIN PAST TWO 2 YEARS Indicate the number of times for each area that applies 1 s Participation at staff conferences 2 Attendance at AAFCP annual meetings 3 Attendance at other Academy approved meetings 4 The Medical and Surgical Applications of NaProTechnology by Thomas W Hilgers MD Complete and include documentation form 5 Review of audio video tapes from AAFCP approved continuing education programs Minimum of 10 contact hours required for this choice 6 Completion2. AAJ P APPLICATION FOR RENEWAL OF CERTIFICATION OF THE FERTILITYCARE INSTRUCTOR Your Application Reviewer is here to help Please see page 8 of this application for instructions on obtaining the name of your Application Reviewer If you have questions while you are filling out your application please email your Application Reviewer for assistance We will be pleased to help you Academy of Fertility Care Professionals Application for Renewal of Certification for the Fertility Care Instructor UNLESS OTHERWISE SPECIFIED ALL REQUESTED INFORMATION APPLIES TO CREIGHTON MODEL APPLICANT NAME HOME ADDRESS Street City State Zip HOME PHONE FAX _ EMAIL II NAME OF YOUR SERVICE DELIVERY PROGRAM NAME ADDRESS Street City State Zip PHONE FAX SUPERVISOR S NAME Please submit a copy of your current AAFCP certification or letter verifying when certification was achieved through the Academy Standard 2 0 CODE OF ETHICS Standard 1 0 I have read and agree to accept and adhere to the Code of Ethics of the American Academy of FertilityCare Professionals Standard 1 2 1 Date Signature III FIELD SERVICE TEACHING Standards 4 0 9 0 A Are you currently teaching FertilityCare Yes No 1 Dates of active teaching since date of most recent Academy certification as a practitioner From
3. NG FEE 53 IS NON REFUNDABLE ATTACHMENT 2 USE OF TEACHING TOOLS AND FORMAT Standard 11 0 For Creighton Model Teaching Rate your compliance according to the scale below for each item NETE er Sse ans ee aes 03 25 50 75 1008 hes The Picture Dictionary of the Creighton Model FertilityCare System lst and 2nd Follow ups 2 The user manual 3 The introductory session 4 The FertilityCare System chart 5s The FertilityCare follow up form 6 The observational routine Ta The reproductive category specific cycle review and observational review 8 The pregnancy evaluation 9 Case management 10 Basic method instructions 11 Special method instructions 12 Basic issues 13 Advanced issues 14 General intake form 15 Basic charting 16 Basic chart reading and correcting 17 The teaching schedule 18 Basic principles of follow up 19 Basic organization of the teaching program Page 2 of 2 USE OF TEACHING TOOLS AND FORMAT Continued 20 Individual follow up 21 Pregnancy follow ups 22 Introductory session evaluation form 23 Teacher evaluation form 24 Follow up evaluation form 25 Follow up on all protocols yellow stamps B6 vitamin C Lactinex 26 Follow up on case management of yellow stamps 27 Medical psycho social spiritual problems and recommendations 28 Log book 29 Long term follow up 30 Information cards 3l Intent
4. TO mo yr mo yr 2 If teaching has not been continuous please list intervals when not teaching From To mo yr mo yr From To mo yr mo yr B Do you understand that renewal of certification will be only for Creighton Model FertilityCare Yes No C List all other models of NFP that you teach and the percentage of clients taught in that model MODEL PERCENTAGE OF CLIENTS ITEMS BEYOND THIS POINT REFER ONLY TO CREIGHTON MODEL D Please complete the enclosed Case List for minimum of 3 new clients entering your program in the last 2 years ATTACHMENT 1 These 3 clients must have had a combined minimum total of 10 follow ups Standard 6 2 2 E Number of new clients instructed in the past 2 years In troductory Session and at least one Follow up minimum of 3 required F Number of Follow ups conducted in the past 2 years mini mum of 10 required G Number of Introductory Sessions conducted in the past 2 years minimum of 2 required Standard 7 0 III FIELD SERVICE TEACHING Continued H FertilityCare affiliate Standard 9 2 1 NAME ADDRESS Street City State Zip PHONE FAX EMAIL Geographic proximity of FCP to you number of miles I Cases referred to your FCP affiiate such as pre Peak yellow stamps post Peak yellow stamps for peak type mucus advanced behavioral issues pregnancy evaluations and other
5. advanced cases Standard 10 2 1 CASE REFERRAL REASON DATE PE CLASSIFICATION IV TEACHING CREDITS Standard 3 0 Ten credits are required At least three must be obtained by teaching 3 new clients in the past two years I have obtained 10 teaching credits for Renewal of Certifica tion in the following way s 1 Direct teaching of 3 credits 3 new clients Include each on ATTACHMENT 1 Case List 2 Direct teaching of 1 client 4 10 new clients 1 credit Include each on Case List NOTE If you have claimed all 10 credits by listing 10 new clients proceed to Section V page 6 Obtaining teaching credits through direct teaching of client couples is the preferred means of meeting Standard 3 0 Standard 3 2 1 IV TEACHING CREDITS Continued If additional credits are needed choose from the following options Standard 3 2 2 3 Case conference discussion with a FCP related to advanced case Management and or pregnancy evaluations 5 Hours 1 Credit 4 Formal outreach or professional presentations 10 Hours 1 Credit HOURS CREDITS TOTAL 3 5 NFP Activities 20 Hours 1 Credit HOURS CREDITS a NFP Administrative activities b NFP Nursing related work 3 CR MAX c NFP Fund Raising activities 3 CR MAX d Research in NFP e List similar NFP activity Attach Documentation 1 2 3 TOTAL 6 Atte
6. ion use assessment Comment on each item on which your rating is less than a 5 CHECK LIST FOR APPLICANT HAVE YOU ENCLOSED THE FOLLOWING WITH YOUR APPLICATION Copy of certificate or certification letter Final exam grade sheet ATTACHMENT 1 Case List ATTACHMENT 2 Use of Teaching Tools and Format ATTACHMENT 3 Satisfaction and Confidence Response Certification fee 53 check payable to AAFCP or PayPal receipt emailed to aafcp coc chairman gmail com Paypal is preferable Clients tally of evaluations Photocopy of list of referral sources Photocopy of program statistics form Continuing education documentation Statement regarding privacy confidentiality and individualized instruction Has your letter of reference been requested Yes No APPLICATION CAN BE PROCESSED ONLY AFTER RECEIPT OF ALL THE ABOVE ITEMS
7. ndance at an Annual Meeting of AAFCP attach documen tation 1 Meeting 2 Credits CREDITS 7 Review of audio video tapes of AAFCP approved continuing education programs 10 Contact Hours 1 Credit 4 CR MAX Include documentation form for each HOURS CREDITS TOTAL 1 NFPMCI 1 credit 1 FCPI 2 credits 1 FCSI 3 credits 1 FCEI 3 credits CREDITS TOTAL 8 SUM TOTAL OF TEACHING CREDITS CLAIMED 1 8 V FIELD SERVICE FORMAT Standards 10 0 14 0 VI book A Do you utilize the specific teaching tools and format as prescribed by the Creighton Model FertilityCare education program Yes No Please complete the attached form relevant to your teaching tools format ATTACHMENT 2 Please enclose a statement describing the way in which you maintain individualized instruction privacy and confiden tiality Sign and date Standard 12 2 1 The Commission on Certification may select a case from your Case List to be reviewed in order to assess your in dividualized case management Is the teaching schedule maintained at appropriate inter vals as recommended by Creighton Model Standard 14 0 Yes No For long term follow up do you document that you have at tempted twice to schedule a follow up appointment before considering the client inactive unless they indicate de sire for no further follow up Standard 15 2 1 15 2 2 Yes No FIELD SERVICE
8. of other Academy approved con tinuing education programs of study B Attach certificates or documentation of attendance APPLICANT S SIGNATURE DATE NEXT STEPS Please read very carefully to avoid delays in processing your application l Name and email of Application Reviewer Pay the certification fee Application processing fee of 53 can be made at www aafcp net under the tab Certification Please email a copy of your PayPal receipt to the Chairman at aafcp coc chairman gmail com If you cannot use PayPal and must mail a check please contact the Chairman at aafcp coc chairman gmail com for a mailing address Submit your application and ALL SUPPORTING ATTACHMENTS in one single document or package Electronic submission email attachment is strongly preferred You may find our Electronic Submission Policy on the AAFCP website Your application should be submitted to ONLY your Application Reviewer You will find a list of Application Reviewers on the website Find the one that handles applications coordinating with your last name and submit your application to that individual If you cannot submit your application electronically please email your Application Reviewer for a mailing address Please keep a copy of your application and all attachments in your files Arrange to have your letter of reference emailed directly to the Chairman at aafcp coc chairman gmail com CERTIFICATION PROCESSI
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