LARC PROVIDER APPLICATION - EXISTING PRACTITIONER The Contraception Project aims to increase the equity of access to contraception for low income women/wāhine. Practitioners who wish to deliver Long-Acting Reversible Contraception (LARC) services under this contract, are required to complete a provider application form to ensure that safe and effective sexual and reproductive health care is provided across Te Moana ā Toi. FULL NAME POSITION & ORGANISATION NZMC / NZNC REGISTRATION NO. EMAIL 1. I CURRENTLY PERFORM LARC AND WOULD LIKE TO BE CERTIFIED FOR COMPETENCY (SELECT AS REQUIRED): JADELLE INSERTIONS JADELLE REMOVALS IUD/IUS INSERTIONS IUD/IUS REMOVALS 2. I HAVE COMPLETED THE GOODFELLOW UNIT eLEARNING MODULES (SELECT AS REQUIRED): JADELLE: PROGESTERONE-ONLY IMPLANT INTRAUTERINE CONTRACEPTIVE DEVICES 3. PROVISION OF LARC SERVICES WILL BE UNDERTAKEN AT FACILITIES ABLE TO PROVIDE FULL PROCEDURAL SUPPORT INCLUDING EMERGENCY MANAGEMENT. I CONFIRM RESUSCITATION AND ANAPHYLAXIS TRAINING IS UP TO DATE IN ACCORDANCE WITH MY REGISTRATION BODY 4. PROVISION OF SERVICES WILL BE UNDERTAKEN BY PRACTITIONERS WHO HAVE BEEN TRAINED AND ARE CURRENTLY PERFORMING THESE PROCEDURES (WITHIN THE LAST 12MONTHS). I HAVE RECEIVED TRAINING IN THE PAST AND I AM CURRENTLY PERFORMING THESE PROCEDURES 5. I CONFIRM THAT THE DETAILS ON THIS FORM ARE CORRECT. I understand that certification is self-certified and that the PHO/PHA reserves the right to audit randomly chosen applications and that I may be requested to provide documentary evidence of my activities. I understand that I will be added to a BOPDHB-wide LARC database as a certified LARC service provider. Your details will be available to other providers and practitioners working in the BOPDHB health system. I would be interested in supporting new practitioners as a LARC educator in my area.
SIGNATURE DATE
Contraception Project: LARC Provider Application. Bay of Plenty District Health Board. 22 Nov 2019. Final.
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