1. Helping Babies Breathe® Master Trainer Application Request Background

Space for the HBB® Master Trainer Course is LIMITED. Preference will be given to those who are actively involved in promoting and implementing neonatal resuscitation activities in low-resource settings. The survey that follows will help in evaluating your application. Once accepted, participants are responsible for their own travel, accommodations, and registration fee. You will also need to register online for the workshop, and purchase training materials. INSTRUCTIONS FOR HBB MASTER TRAINER APPLICATION 1. Please complete this application online. 2. Once the applications are received they will be screened by the faculty. 3. You will be contacted via email regarding the status of your application; those accepted will be asked to register on-line at that time. If you have any questions, please contact Victoria A. Flanagan at 603-650-3479 or at Victoria.A.Flanagan@Hitchcock.org

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* 1. My current role/practice preparation is:

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* 2. If you are certified, please designate specialty/areas of certification:

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* 3. Have you ever attended a structured educational program focused on newborn resuscitation?

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* 4.

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* 5. Please indicate the specific structured educational program that you have attended AND been formally prepared as an INSTRUCTOR TO TEACH.

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* 6. I have had experience teaching the following structured resuscitation curriculum in a low-resource setting. (Check ALL that apply)

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* 7. In your current role do you attend births?

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* 8. Please describe the frequency that you encounter infants who are "depressed" or not breathing at the time of birth.

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* 9. Please designate the area of your practice:

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* 10. I have been in practice focused on this population for (please specify number of years).

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* 11. My primary practice setting is:

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* 12. The primary site of my current clinical practice is:

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* 13. In addition to my primary practice site, I have an established practice or relationship to practice or train healthcare providers in a low resource site.

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* 14. Low Resource Setting Practice Site Information

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* 15. I am currently actively working with the following individuals/groups who may be able to assist or facilitate HBB training in the region.

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* 16. Please describe the funding sources that will support your work as a Helping Babies Breathe Master Trainer in this low-resource settings. Check all that apply.

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* 17. We may be developing research studies designed to better understand the effectiveness of the trainers and training materials. Studies of this nature might involve your participation and testing of your clinical and training skills.

TECHNOLOGY ACCESS/TOOLS

Helping Babies Breathe® is a low technology curriculum. However, your access to and comfort with technology may play a role in our potential research initiative.

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* 18. I am currently comfortable with and have access to the following technology tools (check all that apply):

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* 19. On a regular basis (at least weekly) I have access to (check all that apply):

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* 20. I am familiar with and use the following technology tools:

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* 21. In 2011 we had 69 applications for 25 training spots. Please help us chose wisely by providing a brief (300 words or less) description of why you are interested in becoming a Helping Babies Breathe® Master Trainer and how you intend to use this training in the next 3 to 5 years.

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* 22. Please provide complete contact information so that we can communicate with you regarding the status of your application.

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* 23. May age is:

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* 24. My gender is:

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* 25. My primary language is:

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* 26. In addition to my primary language I also speak (please list all):

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* 27. The best description of my English is the following:

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* 28. Thank-you for completing this application.
Please visit the APN Forum website [WWWLCHADKIDS.ORG/APNFORUM]to download the complete brochure and review details outlining registration and equipment purchasing process. These steps will need to be completed AFTER you are accepted into the Master Training Program.

If you would like to provide any additional information to forward your application, please do so below.

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