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