NICU-MT Mentor Group Intake Form

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Name: *

Work Place *

Have you achieved the NICU-MT Certificate? *

Yes

Required

Please provide an overview of your NICU experience thus far. *

If you are currently in a NICU or trying to get into a NICU please provide the following details to the best of your ability:

- Level of NICU

- Number of Beds

- What department you report to

- Primary diagnoses found on your unit

- # of MTs at your facility

- Current MT services offered

- Level of MT Interest/Knowledge from NICU Team

- Any other information you think is noteworthy

Please choose all the topics you are interested in receiving guidance on and discussing over the next 6 months. *

Program Proposal

Program Expansion

Clinical Services - PAL, MNE, Family Support (Level 2 & 3)

Level IV NICU-MT Services

Billing

Research (designing a study, implementing a study, collaborating on a study, etc.)

Supervision (students, colleagues)

Required

Groups will meet once a month for 75 minutes. Please select all the dates and times that you are available. *

Mondays 9:30am EST

Mondays 10:30am EST

Tuesdays 5pm EST

Tuesdays 6:30pm EST

Wednesdays between 9 - 11am EST

Wednesdays 5pm EST

Thursdays 5pm EST

Thursdays 6:30pm EST

Required

Please describe your current goals as a NICU-MT. (i.e. To start a research study, to collaborate more with other disciplines, to increase my work hours, etc.) *

Is there anything else you would like to include regarding your interest in participating in these mentor groups?

Submit

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