MidwesternUniversity
ChicagoCollege of Pharmacy
Department of Experiential Education
Note:Upon completion of this form, print a hardcopy and submit along with your curriculum vitaeor resume via
hardcopy or e-mail to:
Office of Experiential Education
555 31st Street
Downers Grove, IL60515
(630) 515-6477 Fax: (630) 515-6103
E-mail:
If submitting electronically, enter “New Preceptor” in the Subject line of the e-mail.
Preceptor Profile
1.Name:Date:
2. Title:______Male _____Female
3. Site Name:E-mail:
4.Business Mailing Address:
Business Phone:Fax:
5. In which states are you licensed? ______, ______, ______, ______, ______
6. Have you ever been disciplined for violating any state or federal laws governing the practice of Pharmacy?
Yes No
If yes, give details below
- Are you the subject of any pending disciplinary action by any licensing board?
Yes No
If yes, give details below
8. Have you completed or attended a preceptor training program at MWU or any other college of pharmacy or organization/education program (APhA, ASHP, CEI, Pharmacist Letter)? Yes No
If yes, where (list as many as applicable):
When: (19______), (20______);
9. Which of the following degrees have you obtained? (Check all that apply; please specify year).
______BS Pharmacy(19_____), (20_____)______M.B.A.(19_____), (20_____)
______MS Pharmacy(19_____), (20_____)______Ph.D.(19_____), (20_____)
______Pharm.D.(19_____), (20_____)______Other(19_____), (20_____)
10.Which of the following credentials have you obtained? (Check all that apply)
______BCPS______BCNP______CDE______CGP
______BCPP______BCOP______BC-ADM______AE-C
______BCNSP______CDM (specify disease state):______Other:
11.Have you completed residency/fellowship training?______Yes______No
If yes, please check all that apply:
______PGY1______PGY2______Fellowship
12. Have you completed any certificate training courses? ______Yes______No
If yes, please list:______
13.Do you have a current faculty appointment with a school or college of pharmacy?______Yes______No
14.Have you served as a preceptor in an experiential education course offered by a college of pharmacy in the last 24 months?______Yes ______No
15. Length of time at current site:
16. Which course(s) would you want to precept?
______Introduction to Community (P1) ______Introduction to Hospital (P2)
______Advanced Practice Rotation (P4)
Please select type of APPE course
______Community______Chronic Care or Ambulatory Care
______Hospital______Acute Care or General Medicine
______Elective (type): ______Clinical Medical Specialty (type):______
17. Briefly describe the characteristics of your practice setting (hospital, community, nursing home, etc.), patient population, patient-care services. (If preferred, a separate, typed page of the site description can be attached to this form.
______
18. Please share any special requirements or comments that students must be aware of regarding your rotation or practice site.
NOTE:Please be sure to submit your Curriculum Vitae or Resume along with your preceptor profile
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