Demographics and Contact Information
Pronouns (check all that apply):
She/Her/Hers
He/Him/His
They/Them/Theirs
Prefer to self-describe
If you selected Prefer to self-describe, please enter below
Gender identity or expression (check all that apply):
Female
Male
Transgender Man / Trans Man
Transgender Woman / Trans Woman
Non-binary
Genderqueer or Gender fluid
Not listed; please specify below
Enter Other Gender identity
In what Maryland county (counties) is (are) your primary medical practice(s) located?
Allegany County
Anne Arundel County
Baltimore County
Baltimore City
Calvert County
Caroline County
Carroll County
Cecil County
Charles County
Dorchester County
Frederick County
Garrett County
Harford County
Howard County
Kent County
Montgomery County
Prince George's County
Queen Anne's County
Somerset County
St. Mary's County
Talbot County
Washington County
Wicomico County
Worcester County
Primary practice setting(s) (check all that apply):
Hospital network
Independent hospital (not part of a network)
Solo/Private practice (not hospital-based)
Multi-provider, single site practice (not hospital-based, e.g., academic/student health center)
Multi-site practice (not hospital-based, e.g., urgent care, community health clinic)
Planned Parenthood
Independent abortion clinic
Jail/Prison
Other
Other Practice Setting:
Do you work in an emergency or non-emergency department in this hospital network?
Emergency
Non-Emergency
Both
Do you work in an emergency or non-emergency department at this independent hospital?
Emergency
Non-Emergency
Both
Does this practice provide reproductive healthcare exclusively?
Yes
No, we also provide primary care and/or other specialty care
Do these practices provide reproductive healthcare exclusively?
Yes, at least one of my primary medical practices
provides reproductive healthcare exclusively
Yes, all of my primary medical practices provide reproductive healthcare exclusively
No, all of my primary medical practices also provide primary care and/or other specialty care
Ethnicity
Of Hispanic, Spanish, and/or Latine/Latina/Latino/Latinx origin
Not of Hispanic, Spanish, and/or Latine/Latina/Latino/Latinx origin
Racial identity (check all that apply):
American Indian or Alaska Native
Asian or Asian American
Black or African American
Middle Eastern or North African
Native Hawaiian or Pacific Islander
White
Prefer to self-describe
Enter Other Race
In what capacity are you interested in applying for the fellowship?
Track 1 (for current providers only) : Asynchronous curriculum + simulation (2 days, 8 hours/day)
Track 2 (primarily for students but open to current providers) : Asynchronous curriculum + simulation (2 days, 8 hours/day) + 2-week full-time clinical rotation
Professional Biography and Licenses
Current Maryland license(s) (check all that apply):
Certified Nurse Midwife (CNM) / Certified Midwife (CM)
Physician Assistant - Certified (PA-C)
Medical Doctor (MD) / Doctor of Osteopathic Medicine (DO)
Doctor of Nursing Practice (DNP) / Nurse Practitioner (NP) / Certified
Registered Nurse Practitioner (CRNP) / Women's Health Nurse Practitioner (WHNP)
Other
Do you have any inactive licenses, liability coverage cancellations, or scope limitations?
Yes
No
Please explain the circumstances of your inactive licenses, liability coverage cancellations, or scope limitations
Do you currently hold any board certifications?
Yes
No
If you do not have board certifications to list, or would otherwise like to provide information on your completed degree(s) and/or residency (residencies), please select one of the "yes" options below
Yes, I would like to provide information on my completed degree(s) only
Yes, I would like to provide information on my completed residency (residencies) only
Yes, I would like to provide information on my completed degree(s) and residency (residencies)
No, I do not wish to provide that information at this time
How many completed degrees will you be listing?
1
2
3
How many clinical residencies have you completed?
1
2
3
Degree 1
Degree Institution
Degree Type
Date completed (month and year):
Degree 2
Degree Institution
Degree Type
Date completed (month and year):
Degree 3
Degree Institution
Degree Type
Date completed (month and year):
Residency 1
Residency institution
Residency program type
Date completed (month and year):
Residency 2
Residency institution
Residency program type
Date completed (month and year):
Residency 3
Residency institution
Residency program type
Date completed (month and year):
Current Reproductive/Abortion Care Practice
Miscarriage: Medication management
Currently providing
Would like to provide, but in need of training
Would like to provide, but lacking support staff
Not currently providing for another reason:
Enter reason
Miscarriage: Procedural management
Currently providing
Would like to provide, but in need of training
Would like to provide, but lacking support staff
Not currently providing for another reason:
Enter reason
Procedural abortion
Currently providing
Would like to provide, but in need of training
Would like to provide, but lacking support staff
Not currently providing for another reason:
Enter reason
Medication abortion
Currently providing
Would like to provide, but in need of training
Would like to provide, but lacking support staff
Not currently providing for another reason:
Enter reason
With which parts of the medication abortion process have you had clinical experience? (Check all that apply)
Performed ultrasound dating
Provided service counseling
Dispensed or prescribed medications
Performed follow-up ultrasound
Handled patient phone calls or messages
Do you have clinical experience with any of the following? (Check all that apply)
Conscious sedation monitoring and documentation
Diagnosis and management of other emergency/complication
Diagnosis and management of pregnancy of unknown location
IUD removal
IV placement
Management and dispensing of controlled substances/medications
Management of acute hemorrhage
Management of IV fluids
Placement of osmotic dilators (i.e., laminaria, Dilapan)
Placement of post-procedure implantable contraception
Placement of post-procedure IUD
Transabdominal ultrasound dating/biometry/placental location
Transvaginal ultrasound dating
Ultrasound guidance during D&C/D&E
Other
Other Description
None of the above
Barriers to Service Provision - Check all that apply regarding the barriers you are currently experiencing in providing contraceptive, miscarriage, and/or abortion care in practice
Administrative/Logistical barriers
Billing concerns
Clinic/Hospital doesn't allow it (i.e., religious affiliation)
Competing administrative responsibilities (e.g., serving as a provider and clinic director; providing supervision to students/fellows/residents; etc.)
Competing clinical duties in other practices or areas
Concerned about paperwork required to complete
Lack of authority to provide abortion care due to practice's perceived scope of service or institutional policies
Lack of support from administration
Lack of time to set up services
Medical liability coverage perceived to be insufficient
Medical liability coverage proven to be insufficient
Medical liability coverage too expensive
Physical clinic capacity issues (e.g., limited number of exam rooms and/or provider offices)
Reimbursement issues
Other
Other Description
None of the above
Training barriers
Insufficient clinical training or skills
No ultrasound available or no ultrasound training/skills
Time since last training
Other
Other Description
None of the above
Human/Material resource-related barriers
Inadequate clinical tools or resources
Inadequate financial resources to pursue training
Lack of adequate supplies and facilities
Lack of support staff
Lack of qualified candidates for hiring
Professional colleague/leadership resistance
Support staff resistance
Unable to offer benefits or wages that are competitive with other health care organizations
Other
Other Description
None of the above
Community/Safety-related barriers
Concerns about anti-abortion harassment
Family/Friends concerned for my safety
Services not needed in your area/provider market saturation (i.e., lack of patient demand)
Other
Other Description
Availability for Training
How much consecutive time (in hours or days) do you have available to commit to training?
Will your employer allow you to take time off to receive abortion training?
Yes
No
Unsure
Not applicable (i.e., do not need to request employer permission)
How did you hear about the Reproductive Health Fellows program? (Check all that apply)
Maryland Department of Health press release
University of Maryland, Baltimore (UMB) announcement/email
Colleague or professor (UMB)
Colleague (outside of UMB)
Organizational announcement/email (specify organization in "Other", e.g., NAF, CIAC, NPWH, PP, SFP, etc.)
Western Area Health Education Center (AHEC)
Eastern AHEC
Central AHEC
UMB academic program (Fellow student, department newsletter/student bulletin, etc.)
Other
Other Description
