Harding University College of Pharmacy

Abbreviated Curriculum Vitae for Preceptors

Last Name:
First Name:
Middle Name:
Preferred Name:
Current Practice Site:
Position Title:
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:
Work Email:
Work Phone:
Work Fax:
Home 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:
Home Email:
Home Phone:
Alternate Phone:
Education - chronological (commencing with College)
1st
Name of Institution:
Dates Attended:
Discipline and Degree:
2nd
Name of Institution:
Dates Attended:
Discipline and Degree:
3rd
Name of Institution:
Dates Attended:
Discipline and Degree:
Graduate Training (Residency/Fellowship or Post Doctoral)
1st
Name of Institution:
Dates Attended:
Type of Degree:
2nd
Name of Institution:
Dates Attended:
Type of Degree:
3rd
Name of Institution:
Dates Attended:
Type of Degree:
Board Certification(s)
BCPS BCPP CDM CGP CACP Other
Professional Licensure - Please provide a copy of each to the College
1st
	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
License Number:
Dates/Status:
2nd
	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
License Number:
Dates/Status:
3rd
	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
License Number:
Dates/Status:
Employment History - chronological (3 most recent positions)
1st
Current Position Title:
Employer:
Dates:
2nd
Previous Position Title:
Employer:
Dates:
3rd
Previous Position Title:
Employer:
Dates:
Faculty Appointments - chronological (3 most recent positions)
1st
Name of Institution:
Dates:
Department and Rank:
2nd
Name of Institution:
Dates:
Department and Rank:
3rd
Name of Institution:
Dates:
Department and Rank:
Professional Memberships
APA AAHP APhA ASHP AACP NCPA NACDS Other
Professional Committees, Honors, and/or Service Appointments (with dates)
Years of Practice Experience:
Current Preceptor?	Yes No
Years of Precepting Experience:
Current Practice
Community - Independent Community - Chain Ambulatory Care Long-term Care Hospital/Institutional 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 3rd parties for pharmacy services
Other:	Other:
Practice Focus (provide percentage of each)
Adult % Pediatric % Geriatric %
Patient Diversity
African-American % Asian % Caucasian/White % Hispanic % Native American % Other %
Briefly describe the type of experience a student would have at your site and indicate any unique opportunities for learning.
The following information should be complete prior to serving as a Clinical Pharmacy Preceptor
Have you completed an Affiliate Site Profile for HUCOP?  (see form here)     Yes No
Does your State Board of Pharmacy require you to be licensed/certified as a preceptor?   Yes No    - If yes, is your license/certification current?  Yes No
Do you precept students for other schools or colleges of pharmacy?     Yes No     - If yes, which schools or colleges?
Is your pharmacists license active and in good standing with your applicable State Board of Pharmacy?     Yes No
Are your license(s) and certification(s) up-to-date and on file with HUCOP?     Yes No - If no, please fax to 501-279-5525 or submit by email.
Do you have the desire and ability to teach and evaluate students?       Yes No
Have you ever completed a preceptor training course?     Yes No    - If yes, what is the date and name of course?     and - If no, are you willing to complete an online course provided by HUCOP?       Yes No
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: