Site Description Form

Pharmacy Site Description Form

Tell us about your Site by completing this convenient online Site Description Form. If you prefer, you may select one of the following two documents, print them out, complete them and email Darla Zarley, PharmD, Advanced Experience Coordinator or send fax to 702-990-4435.

Site Description Form (.pdf 24K)

Roseman-COP Site Description Form
Site Name:
Email:	(required for online submission)
Street Address:
City:
State:
Zip Code+4:
phone:	(e.g. 702-990-4433)
fax:	(e.g. 702-990-4433)

About the Staff
Rotation Coordinators Name:
Other Pharmacist Preceptors (please list all names):

Hours of Operation
Sunday:	(e.g. 7a-9p)
Monday:
Tuesday:
Wednesday:
Thursday:
Friday:
Saturday:
Type of Practice
(check all that apply)
Ambulatory Care Clinic
Chain Pharmacy
Consultant
Drug Information Center
Federal or Government Agency
Home Health
Hospital Practice Centralized
Hospital Practice Decentralized
Independent Pharmacy
Long Term Care
Mail Order Facility
Nuclear Pharmacy
Pharmacy Benefit Manager
Pharmacy Industry
Professional Organization
If other, please specify:

Site Description
Please provide a brief description of the practice environment, patient populations serviced and any areas of specialization. The information will be used to categorize the practice site for the purpose of student site selection.:

Number of prescription/medication orders per week:
Are compounding services provided?	yes no
What other services are routinely provided to patients at this site, e.g. Durable Medical Equipment, Nutritional Consultations, Disease State Management, etc.?

About Experiential Training
Will students have access to drug information references and/or a library?	yes no
Will students have access to patient information?	yes no
Will students have an opportunity to interact with or counsel patients?	yes no
Will students have access to other health care professionals?	yes no
Will students be involved with pharmaceutical care and provide therapeutic recommendations?	yes no
Does the site currently offer rotations for other schools or colleges of pharmacy?	yes no
How much time do the preceptors at this site typically spend with students?
Number of hours per day?
Number of hours per week?
What other activities, projects, or assignments are required of students?
What if any limits, conditions, constraints and/or concerns exist with respect to precepting students at this practice site?
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