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	Male Female
First Name:
Middle Initial:
Last Name:
Work Address:
City:
State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Dist. of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Other	Zip:
Office Phone
FAX
Alternate Phone #(s)
Preferred Email Address
Alternate Email Address
Type of Practice
Community Hospital/Institutional Ambulatory/Long Term Care Other (explain)
Specialties/Services Provided – check all that apply
HEALTH-SYSTEM	COMMUNITY/AMBULATORY
Drug information	Compounding
Renal dosing	Diabetes screening
Med history/patient counseling	Durable medical equipment
Pharmacokinetics	Cholesterol screening
Medication use evaluation	Home infusion
Investigational drug use management	Osteoporosis screening
Formulary management	Medication therapy management
Code team participation	Blood pressure screening
Therapeutic protocol development	Immunizations
Patient care rounds	Community educational offerings
ADR/medication error reporting	Dispensing to long term care facilities
Culture surveillance	Billing third parties for pharmacy services
Other:	Other:
Hours of Operation:
Scripts per Day (if applicable):
Patients per day:
Number of Pharmacists:
Length of Pharmacist Shifts:
Number of Technicians:
Length of Technician Shifts:
Number of Interns/Semester:
Length of Intern Rotations:
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	Yes No
Affiliation Agreement signed and on file with the College	Yes No
Reasonable driving distance from campus (IPPEs only)	Yes No
Primary site internet access	Yes No
Environment conducive to learning	Yes No
Serve as preceptor site to other Colleges of Pharmacy*	Yes No
*if yes, please identify
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
1st
Name:
State Pharmacy License #(s):
Preceptor/Alternate Preceptor:
2nd
Name:
State Pharmacy License #(s):
Preceptor/Alternate Preceptor:
3rd
Name:
State Pharmacy License #(s):
Preceptor/Alternate Preceptor:
4th
Name:
State Pharmacy License #(s):
Preceptor/Alternate Preceptor:
5th
Name:
State Pharmacy License #(s):
Preceptor/Alternate Preceptor:
6th
Name:
State Pharmacy License #(s):
Preceptor/Alternate Preceptor:
As Site Coordinator, please ensure that every Clinical Pharmacy Preceptor is aware of the following qualities that are essential prior to taking students:
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
Desire and ability to teach and evaluate students
Desire and ability to develop and/or improve teaching skills