Preceptor Affiliate Clinical Instructor Application and Information Form

Transcription

1 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 Address (Only given to student with permission.) Will you allow us to give address out to students assigned to you? YES NO **Please make special note: Our system is entirely electronic. We MUST have a valid address for generation of assessments and preceptor communication. Please notify our office if your 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? Are you able to accommodate students for 40 or more contact hours per week? YES NO Normal time the student is expected to be at the site (e.g. Mon-Fri 7:00 a.m. 5:00 p.m.) 1 Revised May, 2011

2 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 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: > 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? YES NO 2 R evised May, 2011

3 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 Pharm.D. Pharmacy Resident / Fellows MS PhD Pharmacy Techs RN MD PA or NP Other please specify 3 R evised May, 2011

4 Professional Services check all area(s) in which you (individually) provide service: Anticoagulation Monitoring Community/Group Education Medication Therapy Management Medication Reconciliation Dispensing/Packaging Durable Medical Equipment Hospice Care Clinical Research Drug Information Center Drug Utilization Reviews Health Screening Clinic Patient Discharge Consult Pharmacist Involved on Code Teams Pharmacist Involved on Daily Rounds Pediatric Inpatient Services Home Care Primary Care Pharmaceutical Industry/Academic Detailing Infectious Disease Services Emergency Medicine Geriatrics/Long-Term Care Specialized Pharmaceuticals Veterinary Services Critical Care Unit Compounding (non-sterile) Compounding (sterile) Governmental Agency Mental Health Services Pharmacokinetic Monitoring P & T Committee Functioning Pharmacy Newsletter Poison Control Center OTC Counseling Disease State Management Immunizations Nutrition Support Oncology Services Cardiology Services Nuclear Pharmacy Services Association Management Medical Writing/CE Program Development Neurology Services Nephrology Services Fertility Services Smoking Cessation Other (Please List) Does your site utilize an electronic medical record? Yes No Not Applicable What is the name of your pharmacy dispensing software vendor, if applicable? 4 R evised May, 2011

5 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 5 R evised May, 2011

6 Preceptor Expectations and Agreement The preceptor for the McWhorter School of Pharmacy must: be licensed for a minimum of one year, and in good standing by the respective board of pharmacy as required by the practice environment; complete an Preceptor Affiliate Clinical Instructor Application and Information Form; serve as an exemplary professional role model and instructor for students; have the desire, time, and support (technical, administrative and staff) to facilitate the student s learning process and to assess the student s performance; maintain an ethical and MSOP values-sensitive practice; provide an orientation to the required activities and objectives of the rotation for the student prior to the experience or at the start of the experience ; provide feedback throughout the experience and perform the necessary written evaluations in a timely manner; be in communication with the Experiential Program in regards to any foreseeable questions, issues, or concerns (e.g. scheduling conflicts, student performance, student professionalism, etc.); maintain student confidentiality; abide by all policies of the experiential program ; maintain a positive and progressive outlook for the progression of pharmacy; complete the MSOP preceptor orientation; provide learning experiences that meet the goals and objectives for the particular practice experience; be responsible for interacting with and supervising the student on a regular basis. Preceptors are also responsible for identifying an acceptable replacement to supervise students during absences. recognize where the student is in the curriculum and evaluate him/her based on their didactic experience. Signature and Date 6 R evised May, 2011