Idaho Midwives Peer Review Data Form

 •   Midwife’s Name ___________________________________________________
 •   Practice Name ____________________________________________________
 •   Certification or license #  ________________________________
 •   Date and location of Peer Review  _____________________________________
 •   Dates Reviewed   From: ________________ to  __________________
 •   Number of midwives present (including students & apprentices)  _____________
 •   Total number of clients currently in the midwife’s care _____________
 •   Number of upcoming due dates  _______________
 •   How many women in the practice are postpartum?  _______________
 •   Number of births done since your last Peer Review  _______________
 •   Number of Homebirths completed __________________
 •   Number of Birth Center births completed _______________
 •   Number of transports _________________
 •   Number of clients risked out during this period  ______________
 •   Number of clients requiring consultation or referred antepartum  ________________
 •   Number of clients that left practice for other reasons __________________
 •   Number of cases the midwife has to present ________________
 

Signed: _______________________________________

Witness: ______________________________________

Date: ________________________________________                                                                                                                                                                                                                             4/2010

Total number of cases presented__________                 Total hours__________