Doula Training Organization Evaluation: Pre-Approval Form

Doulas who apply to the Illinois Medicaid-Certified Doula Program must be trained to support clients during the prenatal, labor and delivery, and postpartum periods (referred to as "perinatal training").

This form collects information on the specific topics and activities your training organization requires of participants.

TRAINING ORGANIZATION INFORMATION

Organization Name:

Physical Location:

Please list your mailing address and your phone number.

Online Addresses:

Please list your email address and your web address (URL).

Your Name:

Please indicate your name and your title associated with the organization.

TRAINING PROGRAM CURRICULUM

PLEASE NOTE:

The information provided in this section will be evaluated by personnel who do not have previous knowledge of your training program.

It is important to describe and define any terms or language that are unique to your organization or that may not be widely understood.

Training Program:

Title of the perinatal doula training program

Total Learning Hours:

Indicate the total number of learning hours which includes:

(1) The total hours of live instruction and time working with a doula mentor

AND

(2) The total hours of out-of-class learning, such as online self-learning and reading or research.

PLEASE NOTE: A minimum of 40 total learning hours are required for program approval.

(1) Hours of Live Instruction/Mentorship:

Indicate the total number of instructor-led and/or mentor-led learning hours. This learning time may be in-person at a physical location or online. All online instruction time counted in this section must be live, not pre-recorded.

PLEASE NOTE: A minimum of 28 hours of live instruction/mentorship are required for approval.

(2) Hours of Out-of-Class Learning:

Indicate the total number of hours that learners are expected to be engaged in self-directed learning, such as reading texts/materials, researching, and completing assignments.

Common Training Elements

Please indicate if the following common training elements are required. This section is not evaluated; it serves as documentation only.

HIPAA:

Are HIPAA rules (as they pertain to doula services) included in the curriculum training?

CPR or Basic Life Support:

Is either CPR or BLS included in the curriculum training?

Trauma-Informed Care:

Is trauma-informed care included in the curriculum training?

Implicit Bias/Cultural Competency:

Is implicit bias or cultural competency included in the curriculum training?

Anatomy and Physiology:

Is anatomy and physiology related to pregnancy and birth included in the curriculum training?

Training Related to Prenatal, Labor & Delivery, and Postpartum Care & Support

Prenatal Care and Support:

List and describe all topics included in the curriculum that are related to prenatal care and support.

Labor and Delivery:

List and describe all topics included in the curriculum that are related to labor and delivery care and support.

Postpartum Care and Support:

List and describe all topics included in the curriculum that are related to postpartum care and support.

Training Related to Newborn Care, Scope of Practice, and Ethics

Newborn Health and Care:

List and describe all topics included in the curriculum that are related to the health and care of newborns.

Scope of Practice, Ethics, and Additional Topics:

List and describe topics included in the curriculum that are related to scope of practice, ethical standards (such as continuity of care and service agreements), and any additional topics.

Assessment

Required Assignments:

List the required assignments that learners must successfully complete in order to meet your training requirements.

Hands-On, Practical Experiences

Required Prenatal and Postpartum Experiences:

Describe required prenatal and postpartum experiences, such as shadowing a mentor doula during prenatal or postpartum client visits.

Required Labor and Delivery Experiences:

How many labor and delivery experiences are learners required to attend?

Additional Practical Experiences:

Describe other hands-on experiences that learners are required to attend.

Documentation

Please upload the following required documents:

Learning materials provided to students, such as workbooks, student handbook, syllabus, content outline, and other materials provided to students
Instructor materials such as lesson plans or an instructor handbook
A blank certificate of completion (The certificate will be used to verify IMCD doula applicants who indicate they have completed your program.)
Resumes of training faculty

NOTE: The uploaded documentation should support and confirm the information provided in this form, including common trainings.

Training Program Materials and Resume(s) -- File Upload

Drop your files here

Verify Accuracy and Authenticity

I attest the information provided is accurate.

Typing your name below constitutes your signature.

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Questions or Concerns?

Please contact the Illinois Medicaid-Certified Doula Initiative at doulacertification@siumed.edu.

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