Traditional Health worker Full Certification and Registry ...
|OFFICE OF THE DIRECTOR |[pic] |
|Office of Equity and Inclusion | |
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Birth Doula State Registry Certification Checklist
You must send this form with your Traditional Health Worker (THW) Application when applying for state certification as a THW birth doula. Be sure to send all the items listed below and sign the statements below.
|Doula contact information |
| | | | |
|Doula’s name | |Phone number |
| | |
|Email (personal email recommended) | |
|Required documents |
| A clear copy of a government-issued identification |
|Certificates of attendance for the following education: |
|At least 28 contact hours of in-person education, that includes any combination of childbirth education and birth doula training. |
|At least six contact hours of cultural competency. |
|At least six contact hours total in one or more of the following topics as they relate to doula care: |
|Inter-professional collaboration |
|Health Insurance Portability and Accountability Act (HIPAA) compliance |
|Trauma-informed care |
|An OHA-approved oral health training (Beginning October 2017) |
|Current CPR certification for children and adults |
|Verification of attendance at births and postpartum visits |
|“I, ________________________________ (name of doula) attest that I have completed attendance at three births in the capacity of birth doula. These births |
|occurred after my doula training date. I understand that falsifying this information will result in immediate revoking of my state certification. In addition, I|
|may be ineligible to apply to be on the registry in the future. I understand there may be an audit on proof of attendance at these births and I must supply |
|documentation as requested.” |
|“I, ________________________________ (name of doula) attest that I have completed attendance at three postpartum visits with clients I provided labor support |
|for in the capacity of birth doula. These postpartum visits occurred after my doula training date. I understand that falsifying this information will result in |
|immediate revoking of my state certification. In addition, I may be ineligible to apply to be on the registry in the future. I understand there may be an audit |
|regarding proof of attendance at these births and I must supply any documentation as requested.” |
|Signature: | |Date: | | |
| |
|Proof of completed community resource list |
|“I, ________________________________ (name of doula) hereby attest that I have developed a Community resource list for the counties or geographical area I |
|serve. I understand that falsifying this information will result in immediate revoking of my state certification. In addition, I may be ineligible to apply to |
|be on the registry in the future. I understand there may be an audit regarding proof of completing a community resource list and I must supply any documentation|
|as requested.” |
|Signature: | |Date: | | |
| |
You can get this document in other languages, large print, braille or a format you prefer free of charge. Contact the Traditional Health Worker Program at 1-844-882-7889 or email thw.program@state.or.us. We accept all relay calls or you can dial 711.
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