The A.C.N.M. Foundation, Inc. Reviewer Questionnaire
RequiredRequired Question(s)
Required 1.
Please enter the information indicated below.

First Name:
Last Name:
Company Name:
Work Phone:
Home Phone:
Email Address:
emailaddress@xyz.com
Address 1:
Address 2:
City:
State/Province
(US/Canada):
Postal Code:
Country:
Cell Phone:

2.

May we text you?

Yes
No
3.
What is your age?
< 25
26 - 35
36 - 50
51 - 65
> 65
Prefer not to answer
4.
What is your gender? 
Female
Male
Prefer not to answer
Other  
5.

What is your race / ethnicity? (check all that apply)

American Indian/Alaska Native
Asian Pacific Islander
Black/ African American
Caucasian/Euro-Americ-
an/White
Hispanic/Latino
Native Hawaiian/Pacific Islander
Prefer not to answer
Other  
6.

What are your clinical / professional credentials? (check all that apply)

CNM/CM
FACNM
NP
RN
MD / DO
None
Other  
7.

If CNM / CM, in what year were you certified?

 

50 characters left.
8.

Are you an ACNM member?

Yes
No
9.

If yes, what is your ACNM membership number?

 

50 characters left.
10.

What are your academic degrees? (check all that apply)

Associate
Bachelors
MA
MS
MSN
MPH
PhD
ScD
DrPH
DNSc
DNP
ND
Other  
11.
Please list school and major for each masters and doctoral degree checked above. 
 

1000 characters left.
12.

What is your current professional position?

 

50 characters left.
13.

At what organization? (please include location, city/state)

 

350 characters left.
14.

What is your other current or previous professional position?

 

50 characters left.
15.

At what organization? (please include location, city/state)

 

350 characters left.
16.
In which of the following clinical practice settings have you practiced? (check all that apply)

Academic Medical Center
Private
Public
FQHC/CHC/Health Center
Hospital
Birth Center
Home Birth
Public Health
Military/Federal Government
Other  
17.
Please list any clinical administrative experience; position(s) and years in position.
 

1000 characters left.
18.

Do you have experience in midwifery education?. 

Yes
No
19.

If you have been on a midwifery education program teaching faculty, indicate Program(s) and years teaching.

 

350 characters left.
20.

If you have been a clinical preceptor for midwifery education, please indicate Program(s.)

 

350 characters left.
21.

If you have any other midwifery education experience, please describe.

 

350 characters left.
22.

Do you have academic teaching experience? (other than midwifery education)

Yes
No
23.

If you have taught at the Masters Level, please list institution(s)

 

350 characters left.
24.

If you have taught at the Doctoral Level, please list institution(s)

 

350 characters left.
25.

If you have been a Doctoral Student Dissertation Advisor or Reviewer, please list institution(s).

 

350 characters left.
26.

If you have research-related teaching experience, please describe.

 

350 characters left.
27.

Do you have research experience?

Yes
No
28.

If yes, in what capacity and how many years have you been involved in research-related activities?

 

350 characters left.
29.

If you have received grants to support your research activities, please list the names of the entities that awarded your three most significant grants.

 

350 characters left.
30.

Have you ever been a research or education grant reviewer? If so, please list agencies.

 

350 characters left.
31.

Do you have publication experience as an author or reviewer? If yes, briefly describe.

Yes
No
  • Comment:

  • 500 characters left.
32.

Do you have policy or leadership experience? If yes, briefly describe.

Yes
No
  • Comment:

  • 500 characters left.
33.

Do you have International experience? If yes, briefly describe.

Yes
No
  • Comment:

  • 500 characters left.
34.

Do you have experience with historical research or related Interview experience? If yes, briefly describe.

Yes
No
  • Comment:

  • 500 characters left.
35.

Do you have experience with nonprofits or NGOs? If yes, briefly describe.

Yes
No
  • Comment:

  • 500 characters left.
36.

Do you have experience working with or researching any special populations or groups? If yes, briefly describe.

Yes
No
  • Comment:

  • 500 characters left.
37.

Do you have other information you wish to share?

 

350 characters left.
Required 38.
Confidentiality and Disclosure Agreement

This Confidentiality and Disclosure Agreement (the "Agreement") by and between The A.C.N.M. Foundation, Inc. ("ACNMF"), a 501(c)3 nonprofit corporation incorporated in the State of New York and you. 

In connection with The A.C.N.M Foundation, Inc.'s Award Application Review Processes, you may be given or have access to certain information of ACNMF (collectively, "Confidential Information"). Confidential Information is all information that ACNMF considers confidential or proprietary information of ACNMF regardless of whether such information is marked as such by ACNMF. Confidential Information shall include, but is not limited to, information regarding the organization, operations, programs, activities, policies, procedures, practices, financial condition, trade secrets, membership lists, and standards of ACNMF, its members, or third parties. Confidential Information also shall include, but is not limited to, unpublished or pre-release versions of ACNMF standards, white papers, and other documents and information, or internal use only or limited circulation documents and information.

Specifically, you will receive access to:

Applications to The A.C.N.M. Foundation, Inc.'s various scholarships, awards and grants programs for the purpose of reviewing them for funding consideration.

By agreeing below, you covenant and agree not to disclose or permit to be disclosed any Confidential Information, and that you will not appropriate, photocopy, reproduce, or in any fashion replicate any Confidential Information without the prior written consent of ACNMF. You agree that any disclosure of Confidential Information in violation of this Agreement shall cause immediate and substantial damage to ACNMF and to any parties that provided the Confidential Information to ACNMF. You agree to use reasonable efforts to maintain the confidentiality of the Confidential Information and agree not to use any Confidential Information for its own benefit or that of a third party unless authorized in advance in writing by ACNMF. Confidential Information shall not include information that enters the public domain through no fault of yours or which the you rightfully obtain from a third party without comparable restrictions on disclosure or use.

By agreeing below, you also certify that you will notify The A.C.N.M. Foundation, Inc. if you recognize a duty to disclose a personal or professional relationship with any party's application and will recuse yourself from that application process.


I agree
I do not agree