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:
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