Spotlight Nomination

As part of the Drug Store News CE Pharmacist's Journal, community pharmacies who are implementing patient services and programs to drive pharmacy quality will be highlighted. Use this form to nominate a community pharmacy making a difference in providing care with positive impacts on the health care system.

Name of nominated pharmacy:

Question Title

* 1. Name of nominated pharmacy:

Location of nominated pharmacy:

Question Title

* 2. Location of nominated pharmacy:

Types of quality / performance- related services offered (check all that apply):

Question Title

* 3. Types of quality / performance- related services offered (check all that apply):

Details about the staff of the nominated pharmacy (number of Pharmacists, Residents, Technicians, & Clerks):

Question Title

* 4. Details about the staff of the nominated pharmacy (number of Pharmacists, Residents, Technicians, & Clerks):

Details about the population served by this pharmacy (demographics, special circumstances, etc.):

Question Title

* 5. Details about the population served by this pharmacy (demographics, special circumstances, etc.):

List at least 3 reasons why this pharmacy should be spotlighted:

Question Title

* 6. List at least 3 reasons why this pharmacy should be spotlighted:

Please provide a name of a key contact at the site who can assist with providing additional information for the DSN Pharmacist's Journal Spotlight:

Question Title

* 7. Please provide a name of a key contact at the site who can assist with providing additional information for the DSN Pharmacist's Journal Spotlight:

Please provide an email address of the key contact at the pharmacy:

Question Title

* 8. Please provide an email address of the key contact at the pharmacy:

Does this pharmacy have corporate approval polices or requirements to be met before the DSN Pharmacist's Journal Spotlight can be published?

Question Title

* 9. Does this pharmacy have corporate approval polices or requirements to be met before the DSN Pharmacist's Journal Spotlight can be published?

If yes, please provide contact information for the appropriate approver:

Question Title

* 10. If yes, please provide contact information for the appropriate approver:

Enter your contact information (OPTIONAL)

Question Title

* 11. Enter your contact information (OPTIONAL)

T