HARDING UNIVERSITY
COLLEGE OF PHARMACY
ABBREVIATED CURRICULUM VITAE FOR PRECEPTORS
Last Name First Name Middle Name
Preferred Name Title
Work Address City Zip CodeState
Work Email
Home Address City Zip CodeState
Home Email
Work Phone Work Fax
Home Phone Alternate #
Discipline and Degree
Education - chronological (commencing with College)
Discipline and Degree
Dates Attended
Name of Institution
Dates Attended
Name of Institution
Dates Attended
Discipline and Degree
Name of Institution
Dates Attended
Type or Degree
Graduate Training (Residency/Fellowship or Post Doctoral)
Type or Degree
Dates Attended
Name of Institution
Dates Attended
Name of Institution
Type or Degree
Name of Institution
Professional Licensure - Please provide a copy of each to the College
Dates/Status
License Number
State State
Dates/Status
License Number
State
Dates/Status
License Number
Dates
Dates
Employment History - chronological (three most recent positions)
Dates
Employer
Position Title
Employer
Position Title
Employer
Position Title
Department and RankDepartment and Rank
Faculty Appointments - chronological (three most recent positions)
Department and Rank
Dates
Name of Institution
Dates
Name of Institution
Dates
Name of Institution
Board Certification(s)
OtherBCPS BCPP CDM CGP CACP
(PLEASE COMPLETE BOTH PAGES)
Harding University College of Pharmacy Office of Experiential Education Box 12230 Searcy, AR 72149 (501) 279-5205
AR
AL
AR
AR
AR
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Adult %
HARDING UNIVERSITY COLLEGE OF PHARMACY
ABBREVIATED CURRICULUM VITAE
Page 2 of 2
Professional Memberships
NACDSAPA AAHP APhA ASHP AACP
NCPA Other
MILast Name First Name
Professional Committees, Honors, and/or Service Appointments (with dates)
Years of Practice Experience Current Arkansas Preceptor?
Current Practice
Community - Independent Community - Chain Ambulatory Care Long-term Care
Other (explain)Hospital/Institutional
ADR/medication error reporting
Specialties/Services Provided – check all that apply
HEALTH-SYSTEM COMMUNITY/AMBULATORY
Drug information
Renal dosing
Med history/patient counseling
Pharmacokinetics
Medication use eval
Investigational drug use mgt
Formulary management
Code team participation
Therapeutic protocol development
Patient care rounds
Cholesterol screening
Dispensing to long term care facilities
Compounding
Diabetes screening
Durable medical equipment
Home infusion
Osteoporosis screening
Medication therapy mgt
Blood pressure screening
Immunizations
Community educational offerings
Culture surveillance
Other:
Billing third parties for pharmacy services
Yes (provide verification) No (contact the OEE)
Yes (provide verification) No (contact the OEE)
Other:
Years of Precepting Experience Preceptor Training Complete?
Practice Focus (provide percentage of each)
Geriatric %
Pediatric %
Patient Diversity
African-American %
Asian % Caucasian/White %
Hispanic %
Other %Native American %
Briefly describe the type of experience a student would have at your site and indicate any unique opportunities for learning.
The following information is optional and used only for internal statistical analysis:
Male Female African-American Asian Caucasian/White Hispanic Native American Other
Date of Birth
Current Affiliate Site Profile complete and on file with College
Recognized as a Pharmacy Preceptor for other schools or colleges of pharmacy
License(s) and certification(s) up-to-date and on file with the College
Curriculum Vitae complete and on file with the College (this document satisfies this requirement)
Active and in good standing with the Arkansas State Board of Pharmacy (or responsible Board if outside of Arkansas)
Recognized as a Certified Pharmacy Preceptor/Alternate Preceptor by the Arkansas State Board of Pharmacy, if applicable
If yes, which schools or colleges?
Desire and ability to teach and evaluate students
Desire and ability to improve teaching skills
The following information should be complete prior to serving as a Clinical Pharmacy Preceptor
Harding University College of Pharmacy Office of Experiential Education Box 12230 Searcy, AR 72149 (501) 279-5205
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