APPLICATION FOR RENEWAL OF CERTIFICATION OF
Contents
1. APPLICATION FOR RENEWAL OF CERTIFICATION OF THE FERTILITYCARE PRACTITIONER 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 American Academy of FertilityCare Professionals Application for Renewal of Certification for the FertilityCare Practitioner UNLESS OTHERWISE SPECIFIED ALL REQUESTED INFORMATION APPLIES TO CREIGHTON MODEL APPLICANT II NAME HOME ADDRESS Street City State Zip Country HOME PHONE FAX EMAIL NAME OF YOUR SERVICE DELIVERY PROGRAM NAME ADDRESS Street City State Zip PHONE FAX SERVICE DELIVERY PROGRAM SUPERVISOR S NAME IF APPLICABLE NOT EDUCATION PROGRAM SUPERVISOR 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 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 D Are you currently teaching FertilityCare Yes No 1 Dates of2. Hilgers MD On a separate sheet document the pages you read 5 Review of audio video tapes from AAFCP approved continuing education programs Minimum of 10 contact hours required for this choice Attach documentation form which can be found on our website for each 6 Completion of other Academy approved continuing education programs of study CONTINUING EDUCATION LENGTH OF TIME DATE OF PROGRAM SPENT AT EVENT ATTENDANCE B Attach certificates or documentation of attendance APPLICANT S SIGNATURE DATE NEXT STEPS Please read very carefully to avoid delays in processing your application 1 Paythe 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 a gmail com If you cannot use PayPal and must mail a check please contact the Chairman at aafcp coc chairman 2 gmail com for a mailing address 2 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 Only applications in a single file as outlined in the policy will be accepted 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 wi
3. active teaching since date of most recent Academy certification as a practitioner From 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 Do you understand that renewal of certification will be only for Creighton Model FertilityCare Yes No 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 Please complete the enclosed Case List for minimum of 3 new clients and no more than 10 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 Number of new clients instructed in the past 2 years Introductory Session and at least one Follow up Minimum of 3 required and no more than 10 please Number of Follow ups conducted in the past 2 years minimum of 10 required Number of Introductory Sessions conducted in the past 2 years minimum of 2 required Standard 7 0 III FIELD SERVICE TEACHING Continued H Pregnancy Information for those clients entering program in last 2 years Standard 9 0 1 Number of pregnancies in case load within the last 2 years Number of pregnancy evaluations completed in the last 2 years 2 Numbers of Pregnancy Evaluations completed In
4. Fund Raising activities 3 CR MAX Research in NFP e Academy approved Staff Conferences f List similar NFP activity Attach Documentation 1 2 3 TOTAL 5 Attendance at an Annual Meeting of AAFCP attach documentation 1 Meeting 2 Credits CREDITS IV TEACHING CREDITS Continued 6 Review of audio video tapes of AAFCP approved continuing education programs 10 Contact Hours 1 Credit Four credits maximum Attach Documentation HOURS CREDITS TOTAL 7 Participation as an FCE or FCS in an Academy accredited Education Phase EP 1EP 1 Credit Name of Education Dates of EP Your Program s s Responsibility CREDITS TOTAL 7 8 Supervising Interns by FCE or FCS Name of Education Dates of Program SP s CREDITS TOTAL 8 SUM TOTAL OF TEACHING CREDITS CLAIMED 1 8 V FIELD SERVICE FORMAT Standards 10 0 14 0 A Doyouutilize the specific teaching tools and format as prescribed by the Creighton Model FertilityCare education program Yes No B Please complete the attached form relevant to your teaching tools format ATTACHMENT 22 C Please enclose a statement describing the way in which you maintain individualized instruction privacy and confidentiality Sign and date Standard 11 2 1 D The Commission on Certification may select a case from your Case List to be reviewed in order to assess your individualized case management E Is the teaching schedule maintained at appropriate
5. HING TOOLS AND FORMAT Standard 11 0 For Creighton Model Teaching Rate your compliance according to the scale below for each item 10 11 12 13 14 15 16 17 18 19 1 NEVER 076 2 3 4 5 RARELY SOMETIMES USUALLY ALWAYS 2596 50 75 100 The Picture Dictionary of the Creighton Model FertilityCare System 1st and 2nd Follow ups The User Manual The Introductory Session The FertilityCare System chart The FertilityCare Follow Up Form The Observational Routine The reproductive category specific cycle review and observational review The pregnancy evaluation Case management Basic method instructions Special method instructions Basic issues Advanced issues General intake form Basic charting Basic chart reading and correcting The teaching schedule Basic principles of follow up Basic organization of the teaching program Page 2 of 2 USE OF TEACHING TOOLS AND FORMAT Continued 20 21 22 23 24 25 26 27 28 29 30 31 Individual follow up Pregnancy follow ups Introductory session evaluation form Teacher evaluation form Follow up evaluation form Follow up on all protocols yellow stamps B6 vitamin C Lactinex Follow up on case management of yellow stamps Medical psycho social spiritual problems and recommendations Log book Long term follow up Information cards Intention Use Assessment Comment on each item on which your rati
6. Person By Correspondence By Telephone 3 List the number of pregnancies in each classification IIB IIC IID III 4 Were second pregnancy evaluations done for all class IIA or IIl pregnancies Yes No 5 List second pregnancy classifications for all class IIA or IIl Pregnancy Evaluations IIB IIC IID III 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 have obtained 10 teaching credits for Renewal of Certification 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 4 10 1 client 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 Formal outreach or professional presentations 10 Hours 1 Credit Type of Outreach or 4 of Hours Dates presentation HOURS CREDITS TOTAL 3 4 Activities 20 Hours 1 Credit HOURS CREDITS a NFP Administrative activities b NFP Nursing related work 3 CR MAX c NFP
7. intervals as recommended by Creighton Model Standard 13 0 Yes No F 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 desire for no further follow up Standard 14 2 1 14 2 2 Yes No VI FIELD SERVICE DATA Standards 15 0 19 0 A Doyoukeep an annual tally of responses of the evaluations by clients of their teacher and follow up sessions Standard 15 2 1 Yes No B Do you review on a follow up by follow up basis satisfaction and confidence responses of new clients taught Standard 16 2 1 Yes No C Do you keep statistics for your service program including the number of follow ups pregnancy evaluations demographic data client population etc as prescribed by Creighton Model Standard 17 0 Attach copies of each Yes No VII REFERRALS Standard 18 0 Do you maintain a list of the resources you utilize for all areas of referral Please attach list Yes No VIII CONTINUING EDUCATION Standard 19 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 Participation at staff conferences 2 Attendance at AAFCP annual meetings S MA Attendance at other Academy approved meetings 4 The Medical and Surgical Practice of NaProTechnology by Thomas W
8. ng is less than a 5 CHECK LIST FOR APPLICANT HAVE YOU ENCLOSED WITH YOUR APPLICATION THE FOLLOWING Copy of certificate or certification letter ATTACHMENT 1 Case List ATTACHMENT 2 Use of Teaching Tools and Format Certification Fee 50 Or Paypal Receipt Statement and or documentation of teaching credits Continuing education documentation Statement regarding privacy confidentiality and individual instruction APPLICATION CAN BE PROCESSED ONLY AFTER RECEIPT OF ALL THE ABOVE ITEMS Mail or email application and 53 00 check payable to AAFCP or Paypal receipt to your Application Reviewer see page 8 for instructions on obtaining the name of your Application Reviewer CERTIFICATION PROCESSING FEE 53 IS NON REFUNDABLE
9. th 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 Name and email of Application Reviewer CERTIFICATION PROCESSING FEE 53 IS NON REFUNDABLE 8 OT 4J9quinN 2 Reproductive Category Date of Intro Session of FU Date of Last FU Advanced Case Mgmt i e Yellow Stamps specify Advanced Issues specify Referrals Made Re Problems Identified Y N Pregnancy yes or no Pregnancy Classification Documentation of Items Taught Y N 1 Client s Knowledge Y N 2 Client s Application of Knowledge yes or no 3 Client s Intention Use yes or no JUBLWSSOSSY 1 Instructions 2 Assignments Y N 3 Schedulig of Future Appts Y N suon 1 Client chart w assessment amp corrections yes or no 2 Dicussion Points amp Sexuality Y N M JA Y Client Withdrawn Y N reason Uoneoiue o Jo uoneuJojur jeuonippe spasu zey eseo Aue J0J Jeuonippe ue Jo mojaq ppy S ualjo 0 188 Jno jsi eseejd NOILVOIJILLH3O HO ISI 1 3Svo L LN3INHOV LIV ATTACHMENT 2 USE OF TEAC
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