Pharmacy Practice Experience Preceptor Update
Thank you for your continued commitment to precepting for the NSU College of Pharmacy students! In
order to better assist you and our students, please complete this packet with the information and
return to NSU:
Nova Southeastern University
College of Pharmacy, Experiential Education
3200 S. University Drive
Fort Lauderdale, FL 33328
Fax: (561) 805-2266
E-Mail: [email protected]
The packet should include the following in order to be processed in a timely manner:
1. The Updated Preceptor Application.
2. If you are changing sites and the site is out‐of‐state, please include an aerial map of the area
with the address pinpointed. (i.e. Google Maps or Mapquest).
3. Goals and Objectives for the updated rotation(s).
*If you are a preceptor at a REQUIRED pharmacy practice experience, you only need to
send a letter stating that you will follow the College syllabus, including goals, objectives,
and grading format.
As soon as the Experiential Education Offices have received your completed packet, you will be
contacted by a faculty member to set up a site visit to meet with you as well as any other preceptors at
your site.
Please note -- if your store, pharmacy, hospital etc., has a current Affiliation Agreement with the NSU
College of Pharmacy you will only need to be added as a preceptor. If there is no established affiliation
agreement with the NSU College of Pharmacy, the process will take longer to complete. The
application process may take anywhere between 3 to 6 months.
We appreciate your continued support of NSU College of Pharmacy student education and look
forward to working with you to create better communities!
Preceptor Update Form Please fill out completely. You may mail, email or fax the forms to the Experiential Education Office. Preceptor Name: Are You An NSU Alumni?:
Date:
NO
YES Graduation Year?:
Practice Site (Include Site #):
Site Address: Site's Phone Number: Email Address: Fax Number: Check One:
License #: Pharm.D B.S. Pharm Other:
State Issued:
Original Date Issued:
1. Are you updating your experience type? ____ YES _____ NO
2. Mark Experience Practice Type you are interested in:
____ (IPPE) Introductory Pharmacy Practice Experience _____ Community _____ Hospital (Health System and Pharmacy Service) ____ (APPE) Advanced Pharmacy Practice Experience 3. Will Students have potential for regular interprofessional experiences (IPE)?
YES
/
/
NO
4. Which experiences will IPE occur? ____________________________________________________
5. Is this site affiliated with Nova Southeastern University College of Pharmacy?
YES
NO
UNSURE
6. If "No", who will be overseeing the affiliation agreement process? __________________________________
Mark ALL Practice Experience(s) you are interested in offering: Medical Mission
Academic Clerkship
Critical Care
Dermatology
Medication Safety Administration
Disaster Relief Team
Adv. Community
Neonatology Drug Information
Adv. Drug Information
Neurology Drug Treatment
Adv. Geriatrics
Nuclear Medicine Emergency Medicine
Adv. Hospital
Nutritional Support Foreign Study
Adv. Infectious Disease
Oncology/Hematology
General Clinical
Inpatient Oncology
Adv. Internal Medicine
Geriatrics
Operating Room Adv. HIV
Adv. Oncology
HIV
Pain Management Home Infusion
Adv. Psychiatry
Pediatrics Ambulatory Care
Hospice/Pallative Care
Inpatient Pediatrics
Anticoagulation Therapy
Indian Health Services
Pharmacology Research
Inpatient Anticoagulation Therapy
Industry
Pharmacy Benefit Mgmt.
Association
Infectious Disease
Pharmacokinetics Cardiology
Informatics
Psychiatry Clinical Research
Toxicology Internal Medicine
Compounding
Transplant Leadership
Community Pharmacy Management
Veterinary Pharmacy Managed Care
OTHER: