Pharmacy Preceptor Interest Form Thank you for your interest in being a preceptor for University of the Pacific’s Thomas J. Long School of Pharmacy. The Office of Professional Programs staff will contact you after your application has been reviewed. OK Question Title * Contact Information First Name Last Name Email Address Confirm Email Primary Phone Secondary Phone (Optional) OK Question Title * Are you a University of the Pacific alumnus/alumna? Yes No OK Question Title * Do you have experience precepting students? Yes No OK Question Title * Years in practice: OK Question Title * Education (Check all that apply) BS MS PharmD PhD Other (please specify) OK Question Title * Postgraduate Training (Check all that apply) PGY1 PGY2 Fellowship Other (please specify) OK Question Title * Board Certification (Check all that apply) CACP BCPPS BCPS BCPP BCACP BCCC CCGP BCNP BCNSP BCOP Other (please specify) OK Question Title * General Practice Certificate Training CDE Immunization Delivery Medication Therapy Management Cardiovascular Disease Management Pharmacist Centered Diabetes Care Pharmacogenomics Advanced Pharmacy Preceptor Training Other (please specify) OK Question Title * Licensure State Number State Number OK Question Title * Please specify which Introductory Pharmacy Practice Experience (IPPE) and/or Advanced (APPE) rotation(s) you are interested in precepting for, check all that apply. IPPE - Community IPPE - Hospital APPE - Adult/Internal Medicine APPE - Ambulatory Care APPE - Community Practice APPE - Hospital/Institutional Practice APPE Elective (please specify) OK Question Title * Rotation Site Name of Your Organization/Site Address City State -- select state -- AL AlabamaAK AlaskaAS American SamoaAZ ArizonaAR ArkansasCA CaliforniaCO ColoradoCT ConnecticutDE DelawareDC District of ColumbiaFM Federated States of MicronesiaFL FloridaGA GeorgiaGU GuamHI HawaiiID IdahoIL IllinoisIN IndianaIA IowaKS KansasKY KentuckyLA LouisianaME MaineMH Marshall IslandsMD MarylandMA MassachusettsMI MichiganMN MinnesotaMS MississippiMO MissouriMT MontanaNE NebraskaNV NevadaNH New HampshireNJ New JerseyNM New MexicoNY New YorkNC North CarolinaND North DakotaMP Northern Mariana IslandsOH OhioOK OklahomaOR OregonPW PalauPA PennsylvaniaPR Puerto RicoRI Rhode IslandSC South CarolinaSD South DakotaTN TennesseeTX TexasUT UtahVT VermontVI Virgin IslandsVA VirginiaWA WashingtonWV West VirginiaWI WisconsinWY Wyoming ZIP OK Question Title * Does your institution have interest in working with any of the following allied health disciplines? Master of Science in Athletic Training Master of Science in Clinical Nutrition Master of Arts in Music Therapy Master of Physician Assistant Entry Level Master of Science in Nursing Master of Social Work Master of Science in Speech Language Pathology Doctor of Dental Surgery Doctor of Physical Therapy Doctor of Occupational Therapy Doctor of Audiology OK DONE
