ADR/medication error reporting
Harding University College of Pharmacy
Office of Experiential Education (OEE)
Pharmacy Practice Experience
Affiliate Site Profile
To be completed by the Site Coordinator. One profile per site please.
Date Facility
Job Title
Gender
First
Name
Work Address
Zip
Office Phone FAX
Alternate Phone #(s)
Preferred Email Address
Alternate Email Address
Type of Practice
Other (explain)
Hospital/InstitutionalCommunity Ambulatory/Long Term Care
Specialties/Services Provided – check all that apply
HEALTH-SYSTEM COMMUNITY/AMBULATORY
Drug information
(PLEASE COMPLETE BOTH PAGES)
StateCity
Last
Name
Middle
Initial
Male Female
Renal dosing
Med history/patient counseling
Pharmacokinetics
Medication use evaluation
Investigational drug use management
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 management
Blood pressure screening
Immunizations
Community educational offerings
Culture surveillance
Other:
Billing third parties for pharmacy services
Other:
Hours of Operation
Scripts per Day (if applicable) Patients per day
Number of Pharmacists Length of Pharmacist Shifts
Length of Technician ShiftsNumber of Technicians
Length of Intern RotationsNumber of Interns/Semester
Submit by Email
Print Form
Desire and ability to develop and/or improve teaching skills
Desire and ability to teach and evaluate students
Harding University College of Pharmacy
Office of Experiential Education PPE
Affiliate Site Profile Page 2 of 2
For office use only…
Primary site visit conducted by Assistant Dean for Experiential Education Yes __ No __
Preceptor training manual presented and reviewed with preceptor(s) Yes __ No __
Continuing Education opportunities discussed Yes __ No __
ASHP Preceptor's Handbook for Pharmacists provided to preceptor(s) Yes __ No __
Briefly describe the activities a student may experience at your pharmacy (include any unique opportunities)
Primary Site Information Checklist
Class A rating by the Arkansas State Board of Pharmacy
Affiliation Agreement signed and on file with the College
Reasonable driving distance from campus (IPPEs only)
Primary site internet access
Environment conducive to learning
Serve as preceptor site to other Colleges of Pharmacy*
Clinical Pharmacy Preceptor(s)
Please list all of the preceptors available at your site. Each preceptor MUST provide a
curriculum vitae to the Office of Experiential Education. An Abbreviated Curriculum Vitae
Form is available from the OEE for your convenience.
Preceptors/Alternate Preceptors willing to accept students at this site
As Site Coordinator, please ensure that every Clinical Pharmacy Preceptor is aware of the following qualities that are
essential prior to taking students:
Yes No
Yes No
NoYes
Yes No
Yes No
Yes No
*if yes, please identify
Preceptor/Alternate Preceptor
State Pharmacy License #(s)
Name
Preceptor/Alternate PreceptorPreceptor/Alternate Preceptor
State Pharmacy License #(s)
Name
State Pharmacy License #(s)
Name
State Pharmacy License #(s)
Preceptor/Alternate Preceptor
Name
State Pharmacy License #(s)
Preceptor/Alternate Preceptor
Name
State Pharmacy License #(s)
Preceptor/Alternate Preceptor
Name
Recognized as a certified pharmacy preceptor/alternate preceptor by the Arkansas State Board of Pharmacy
Active and in good standing with the Arkansas State Board of Pharmacy
Curriculum Vitae complete and on file with the College
License(s) and certification(s) up-to-date and on file with the College
Submit by Email
Print Form
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