Interest Form

Thank you for your interest in the Clinical Pharmacy Pathway Certificate Training Program. This program will only be offered to a limited number of participants. Participation in this grant program is limited and contingent on available grant funding. Eligibility for participation in this program is determined by a number of factors, including geographic areas of need identified by the Tennessee Department of Health, readiness for implementation of care and services into pharmacy practice, and ability to provide TPREF with key data and clinical endpoints.

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* 1. Please enter your contact information.

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* 2. Do you currently have a collaborative pharmacy practice agreement?

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* 3. Which training dates would you like to attend? (You may select more than one.)

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* 4. What primary pharmacy practice setting do you currently work in?

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* 5. The following information must be collected from program participants at baseline and semi-annually. Please select any items below that you may NOT be able to provide.

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* 6. Please explain your concerns about providing each of the items you selected in Question 5 above.

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* 7. Please provide any comments you have about your participation in this program.

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