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Preceptor Affiliate Clinical Instructor Application and Information Form

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Preceptor – Affiliate Clinical Instructor Application and Information Form

We MUST have this information on file for all preceptors engaged in teaching our students in experiential coursework. The form must be completed upon initial appointment as Affiliate Clinical Instructor and then resubmitted any time you change your practice site or have a significant change to your practice responsibilities.

Date Male

Female

First Name MI Last Name

Maiden Name If Applicable

Credentials (R.Ph., Pharm.D.; D.Ph., MD, Ph.D., etc) Job Title

Name of Practice Site Practice Site Address

City State Zip

Mailing Address If Different

Office Phone Fax Number

Pager PIN Cell Phone

Preferred Email Address (Only given to student with permission.)

Will you allow us to give Email address out to students assigned to you? YES

NO

**Please make special note: Our system is entirely electronic. We MUST have a valid email address for generation of assessments and preceptor communication. Please notify our office if your email address changes at any time.**

Area(s) Of Specialization

Preferred Method for Students to contact you: Work Phone

Email

Cell Phone

Do you have an Alabama Preceptor’s Certificate? YES

NO

If yes, when does your certificate expire?

Are you a preceptor for other schools or colleges of Pharmacy? YES

NO If yes, which schools or colleges?

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Please attach either a current resume/CV to this information form. Pages 1 through 4 must be completed by

all preceptors. Page 5 is only required if you do not attach a resume or CV. These documents may be

transmitted electronically to

jivie@samford.edu

or via fax at 205-726-4214.

Do you provide a work/study area for the student? YES

NO

Do you provide an area for the students to store belongings? YES

NO

Will students have access to the Internet and Samford University’s on-line Drug Information Center Website while at your site? YES

NO

Practice Setting:

Community Pharmacy

Chain Independent Hospital Pharmacy

University

Private

Government Ambulatory Care

Home Infusion / Long Term Care Nuclear

Other – Please describe:

If your practice setting is in a hospital or long term care facility, please indicate the number of beds:

0 – 100 100 – 200 200 – 300 300 – 400 > 400 Do we have permission to highlight our partnership with you and your site on our Website and in our newsletters?

YES

NO

Do you have an internet address of your institution that we can reference or link? YES

NO If Yes, please give us the web address:

Our student evaluations/assessments for experiential courses require on-line submission of all documentation. Will you have online access to complete evaluations/assessments of students in a timely fashion, generally at the midpoint and end of each calendar month?

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Please provide descriptive information about your practice site so students can make informed choices about experiential

course assignments. Briefly describe the type of experience a student would have at your site and indicate any special features

that make your rotation experience unique.

What are the major things a student will learn from spending time from you and the colleagues at your site? Please list 4 or 5.

Please provide detailed driving directions to your site including any special parking instructions

.

Personnel with whom students will interact while on assignment at your site (check all that apply).

BS Pharmacist

Pharmacy Techs

Pharm.D.

RN

Pharmacy Resident / Fellows

MD

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Professional Services – check all area(s) in which you (individually) provide service:

Anticoagulation Monitoring

Critical Care Unit

Community/Group Education

Compounding (non-sterile)

Medication Therapy Management

Compounding (sterile)

Medication Reconciliation

Governmental Agency

Dispensing/Packaging

Mental Health Services

Durable Medical Equipment

Pharmacokinetic Monitoring

Hospice Care

P & T Committee Functioning

Clinical Research

Pharmacy Newsletter

Drug Information Center

Poison Control Center

Drug Utilization Reviews

OTC Counseling

Health Screening Clinic

Disease State Management

Patient Discharge Consult

Immunizations

Pharmacist Involved on Code Teams

Nutrition Support

Pharmacist Involved on Daily Rounds

Oncology Services

Pediatric Inpatient Services

Cardiology Services

Home Care

Nuclear Pharmacy Services

Primary Care

Association Management

Pharmaceutical Industry/Academic Detailing

Medical Writing/CE Program Development

Infectious Disease Services

Neurology Services

Emergency Medicine

Nephrology Services

Geriatrics/Long-Term Care

Fertility Services

Specialized Pharmaceuticals

Smoking Cessation

Veterinary Services

Other (Please List)

Does your site utilize an electronic medical record?

Yes No

Not Applicable

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This page only required if the preceptor does NOT submit a resume or CV.

Education/Degrees

Institution Attended Dates Attended Degree

Post Graduate Training (Residency, Fellowship, etc)

Post Graduate Program Dates Attended Completion Date

Employment History

Position Employer Dates

Professional Licensure

State Where Licensed to Practice License Number

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Preceptor Expectations and Agreement The preceptor for the McWhorter School of Pharmacy must:

• be licensed for a minimum of one year, and in good standing by the respective board of pharmacy as

required by the practice environment;

• complete an Preceptor Affiliate Clinical Instructor Application and Information Form;

• serve as an exemplary professional role model and instructor for students;

• have the desire, time, and support (technical, administrative and staff) to facilitate the student’s learning

process and to assess the student’s performance;

• maintain an ethical and MSOP values-sensitive practice;

• provide an orientation to the required activities and objectives of the rotation for the student prior to the

experience or at the start of the experience ;

• provide feedback throughout the experience and perform the necessary written evaluations in a timely

manner;

• be in communication with the Experiential Program in regards to any foreseeable questions, issues, or

concerns (e.g. scheduling conflicts, student performance, student professionalism, etc.);

• maintain student confidentiality;

• abide by all policies of the experiential program ;

• maintain a positive and progressive outlook for the progression of pharmacy;

• complete the MSOP preceptor orientation;

• provide learning experiences that meet the goals and objectives for the particular practice experience;

• be responsible for interacting with and supervising the student on a regular basis. Preceptors are also

responsible for identifying an acceptable replacement to supervise students during absences.

• recognize where the student is in the curriculum and evaluate him/her based on their didactic experience.

___________________________________________________

References

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