E X P E R I E N T I A L E D U C A T I O N R O T A T I O N A P P L I C A T I O N

ROSEMAN UNIVERSITY OF HEALTH SCIENCES, COLLEGE OF PHARMACY

11 Sunset Way, Henderson, NV 89014

Phone 702-968-2005 / Email

Please select your Roseman contact person:

 Darla Zarley C. Leiana Oswald Erin Johanson Andrew Draper

PRECEPTOR CONTACT INFORMATION

Name:

Title:

Office Phone: / Ext.: / Cell: / Pager:

Preceptor Email (required):

Name of secondary preceptor (optional):

Secondary Preceptor Email (optional):

SITE CONTACT INFORMATION

Site:

Street Address:

City: / State: / Zip:
Main Pharmacy Phone: / Ext.: / Fax:

Site Web Address:

Name of Pharmacy Director or PIC:

LICENSE INFORMATION

Please list states in which you are currently licensed:

State: / License Number:
State: / License Number:
State: / License Number:

Have you ever been disciplined for violating any state or federal laws governing the practice of pharmacy?

Yes No If yes, please provide details:

Are you the subject of any pending disciplinary action by any licensing board?

Yes No If yes, please provide details:

DEGREES AND EDUCATION
Degree: / School: / Year:
Degree: / School: / Year:

Have you completed residency training? Yes No If yes, please check all that apply:

Community / Health System / Ambulatory Care / Acute Care / General / Administrative
Specialty: / Other:

Which of the following credentials have you obtained (check all that apply):

AE-C / BCPS / BCPP / BCNSP / BCNP / BCOP / BC-ADM / CDE / CGP
CDM (please specify disease state): / Other:

Have you completed any certificate training courses? Yes No If yes, please provide details below:

PRECEPTOR INFORMATION

How long have you been employed at your site:

Do you have a current faculty appointment with a school or college of pharmacy? Yes No

If yes, what other colleges/universities are you associated with?

Have you completed or attended a preceptor training program? Yes No If yes, please specify below:

Topic: / Sponsor: / Year:
Topic: / Sponsor: / Year:
Topic: / Sponsor: / Year:

Describe why you wish to participate in the training of future pharmacists:

How do you see your role, as a preceptor, in the education of students?

SITE INFORMATION

Does this site offer residency training? Yes No If yes, what training is provided?

Does this site offer immunizations? Yes No

Does this site offer blood pressure screenings? Yes No

What patient populations are served?

Will students have access to drug information references and/or a library? Yes No

Will students have access to patient information? Yes No

Will students have an opportunity to interact with or counsel patients? Yes No

Will students have access to other health care professionals? Yes No

Will students be involved with pharmaceutical care and provide therapeutic recommendations? Yes No

What activities, projects, or assignments are required of students?

Prerequisite rotations required? Yes No If yes, please specify:

Approximate # of prescriptions filled per day:

Number of beds if hospital:

Do you have a rotation syllabus/schedule for students to follow? Yes (if yes, please attach a copy) No

Site Hours: / MON / TUE / WED / THR / FRI / SAT / SUN

Briefly describe the characteristics of your rotation experience and any unique features:

ACKNOWLEDGEMENT AND SIGNATURE
(ELECTRONIC SIGNATURES ARE ACCEPTED) / Preceptor Initials
I agree to notify the APPE Coordinator should an unexpected absence interrupt student rotations or should I have any concerns during the course of the rotation.
I understand that I may be required to attend preceptor trainings as presented by the university.
I understand the importance of communicating with rotation students on a regular basis. I am willing to meet with the student to discuss their performance, goals, and expectations (at minimum):
a)On the first day of the rotation.
b)At mid-point, when we will also go over the mid-point assessment.
c)Prior to the end of the rotation, when we will go over the final assessment.
I am willing to dedicate time to provide continuous feedback to my rotation student(s).

Signature: