Please fill out the information below to apply as a mentor for the Essential Access Health LARC Mentorship Program. This program aims to develop a network of mentors in Los Angeles County who will support other clinicians performing their initial LARC placements and to provide other LARC-related guidance. This training is for physicians and advanced practice clinicians with expertise in placement and removal of LARC devices who would like to enhance their ability to guide and mentor others. 

A signature from the applicant and confirmation of supervisor support for the applicant is required.

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* 1. Contact Information

Registration

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* 2. I am a licensed clinician (MD/DO, NP, PA, CNM).

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* 3. I live or work in Los Angeles County.

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* 4. I attended or am registered to attend a 2019 Essential Access Health Advanced IUD Training on:

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* 5. AVAILABILITY: What type of mentor assignments can you take on? (Check all that apply)

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* 6. AVAILABILITY: During which hours are you available for IUD or Nexplanon® mentor assignments? (Check all that apply)

  Monday Tuesday Wednesday Thursday Friday Saturday Sunday
Morning
Afternoon
Evening
LARC Experience

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* 7. Indicate the number of placements you have done in the last year for each of the following LARC methods:

  0 1-5 5-10 11-25 26-50 51-100 100+
Paragard®
Mirena®
Liletta®
Kyleena®
Skyla®
Nexplanon®

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* 8. Indicate the number of removals you have done in the last year for each of the following LARC methods:

  0 1-5 5-10 11-25 26-50 51-100 100+
Paragard®
Mirena®
Liletta®
Kyleena®
Skyla®
Nexplanon®

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* 9. MENTORING SKILLS OR QUALIFICATIONS: Please briefly summarize what would make you a good IUD and/or Nexplanon® mentor:

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* 10. MENTORING OPPORTUNITY: Why would this mentor training opportunity be helpful to you?

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* 11. MENTORING EXPERIENCE: Please summarize your previous mentoring experience:

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* 12. How did you hear about the LARC Mentor training?

Liability/Malpractice Insurance Information

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* 13. Please choose which best applies:

If you would like to provide additional information regarding your coverage, please include it below (this is optional)

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* 14. Policy Holder's Name

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* 15. Insurance Company

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* 16. Coverage Effective Date

Date

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* 17. State(s) Covered

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* 18. Please share anything else that you feel will help to clarify information provided or to support your mentor application.

Mentor Agreement & Signature

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* 19. By providing my typed signature below and submitting this application, I affirm that the facts set forth in it are true and complete. I understand that if I am accepted as a mentor, any false statements, omissions, or other misrepresentations made by me on this application may result in my immediate dismissal.

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* 20. Date Signed

Date

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* 21. By typing my signature and submitting this agreement, I affirm that my supervisor supports my effort to act as a LARC mentor. As part of this agreement my supervisor understands that I may have to be offsite as part of the mentoring duties or that we may host another clinician onsite (per agency approval). Our agency will do our best to accommodate these requests in support of the initiative.

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* 22. Date Signed

Date

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