Please view the point system/rubric on the information page to assist with completing this form.
  • If your chapter did not participate in an activity, skip it/leave blank.
  • For the activities your chapter did participate, please include the specific details requested.
  • If you have conducted more than the number of events in any section, choose your most innovative/impactful events to spotlight.
  • Only list each event one time.
  • Points will be verified by the FSHP Professional Affairs Council.

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* 1. Nominated by
Your Name

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* 2. Your Email Address

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* 3. Your Phone

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* 4. Student Chapter

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* 5. Total number of members this academic school year

Section A: Individual Member Activities
Indicate below the total number of members who have received State, Regional or National awards or currently hold leadership positions in any organization at this level. A maximum of 30 points can be earned in this section.

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* 6. Number of members who held a state level office or won a state level award
e.g. Student Poster Winner at FSHP Annual
(3 points per member / do not include FSHP leadership positions, please list those in Section B)

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* 7. Number of members who held a regional level office or won a regional level award
e.g. Regional Student Officer of the South Atlantic Region of Industry Pharmacists Organization
(4 points per member)

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* 8. Number of members who held a national level office or won a national level award
e.g. APhA-ASP National Standing Committee Member, SNPhA National Vice President
(5 points per member)

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* 9. Section A Subtotal (maximum of 30 points accepted)

Section B: Membership in FSHP
A maximum of 50 points can be earned in this section.

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* 10. Percentage of FSHP members to total student body - include all PD years in the count
(<2% = 1 point, 2-5% = 3 points, 6-10% = 5 points, >10% = 10 points / 10 points max)

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* 11. Percent membership increase from previous year
(<2% = 1 point, 2-5% = 3 points, 6-10% = 5 points, >10% = 10 points / 10 points max)

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* 12. Percent of members that attended the last FSHP Annual Meeting
(<2% = 1 point, 2-5% = 3 points, 6-10% = 5 points, >10% = 10 points / 10 points max)

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* 13. Number of members holding FSHP leadership positions - e.g. council members, house of delegates, student director - does not include chapter positions
(1 = 1 point, 2-3 = 5 points, 4+ = 10 points / 10 points max)

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* 14. Number of members holding ASHP leadership positions - e.g. council members, house of delegates, student director - does not include chapter positions
(1 = 1 point, 2-3 = 5 points, 4+ = 10 points / 10 points max)

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* 15. Section B Subtotal (maximum of 50 points)

Section C: Chapter Events
List events that you feel are most creative, innovative, and impactful. A maximum of 55 points can be earned in this section.
DEFINITION OF COLLABORATION WITH FSHP LEADERSHIP: A Student Chapter event that involves a pharmacist who is a FSHP active member. The pharmacist may serve as a speaker, coordinator, volunteer, etc.

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* 16. Event #1 featuring health system speakers
(4 points if no collaboration with FSHP leadership, 5 points if collaborated)

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* 17. Event #2 featuring health system speakers
(4 points if no collaboration with FSHP leadership, 5 points if collaborated)

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* 18. Event #3 featuring health system speakers
(4 points if no collaboration with FSHP leadership, 5 points if collaborated)

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* 19. Event #4 featuring health system speakers
(4 points if no collaboration with FSHP leadership, 5 points if collaborated)

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* 20. Residency training information session
(4 points if no collaboration with FSHP leadership, 5 points if collaborated)

List activities planned by your Chapter where members actively participate to serve patients or the community.

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* 21. Chapter Service Activity #1
(2 points)

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* 22. Chapter Service Activity #2
(2 points)

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* 23. Chapter Service Activity #3
(2 points)

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* 24. Chapter Service Activity #4
(2 points)

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* 25. Chapter Service Activity #5
(2 points)

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* 26. PAI Education Event - PAI information: ashpmedia.org/pai
(4 points if no collaboration with FSHP leadership, 5 points if collaborated)

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* 27. Professional or Leadership Development Event: List an activity planned by your Chapter to develop the leadership or professional skills of the student body
(4 points if no collaboration with FSHP leadership, 5 points if collaborated)

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* 28. Innovative Project - Definition: Innovative project not covered by other categories
(6 points)

List any events or activities planned to raise awareness or funds for the Political Action Committee, Legislative Days or policy

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* 29. Policy/Legislative Event #1
(2 points)

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* 30. Policy/Legislative Event #2
(2 points)

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* 31. Section C Subtotal (maximum of 55 points)

Section D: Donations
A maximum of 3 points can be earned in this section. Please make checks payable to FSHP Research and Education Foundation and mail checks to: FSHP - 2910 Kerry Forest Pkwy D4 Suite 376, Tallahassee, FL 32309

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* 32. Donations to the Research and Education Foundation
($1-250 = 1point, $251-500 = 3 points, $5001+ = 5 points)

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* 33. Section D Subtotal (maximum of 5 points)

Section E: Rubric Feedback
A maximum of 3 points can be earned in this section.

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* 34. Student Chapter Feedback
(1 point per suggestion)

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* 35. Section E Subtotal (maximum of 3 points)

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* 36. TOTAL POINTS EARNED - calculate the total number of points earned in all the above sections (maximum of 143 points)

Student Chapter Photos
Please attach 1-2 photos that represent your Student Chapter below

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* 37. Photo 1

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* 38. Photo 2

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