Abbreviated Curriculum Vitae for Preceptors

Last Name:
First Name:
Middle Name:
Preferred Name:
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 #:
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 (three most recent positions)
1st
Position Title:
Employer:
Dates:
2nd
Position Title:
Employer:
Dates:
3rd
Position Title:
Employer:
Dates:
Faculty Appointments - chronological (three 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 Arkansas Preceptor?	Yes (provide verification) No (contact the OEE)
Years of Precepting Experience
Preceptor Training Complete?	Yes (provide verification) No (contact the OEE)
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 third 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
Current Affiliate Site Profile complete and on file with College
Recognized as a Certified Pharmacy Preceptor/Alternate Preceptor by the Arkansas State Board of Pharmacy, if applicable
Recognized as a Pharmacy Preceptor for other schools or colleges of pharmacy If yes, which schools or colleges?
Active and in good standing with the Arkansas State Board of Pharmacy (or responsible Board if outside of Arkansas)
Curriculum Vitae complete and on file with the College (this document satisfies this requirement)
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 improve teaching skills
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: