Date
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Month
-
Day
Year
Date
Experiential Site Application & Site Inspection Form
Pharmacy Name
Physical Address
Street, City, State, Zip
Mailing Address
if different than physical address
Phone Number
Pharmacy phone number
Fax Number
Pharmacy fax number
Preceptor Name and Title
Email Address of Preceptor
example@example.com
Phone Number
Preceptor's phone number if different than pharmacy's
Pharmacy Services Provided - Check each box for the service the facility provides.
Automation
Customer service
Data entry
Home-infusion services
Inventory
Long-term care packaging
Medication reconciliation
Medication therapy management services
Non-sterile compounding
Patient-specific medication dispensing
Reconstitution
Tech-check-tech
Third-party billing
Wellness services (e.g., immunizations)
Other
If taking multiple students, what is the maximum amount of students you can take?
*Reminder* Technician interns do count towards your pharmacist to technician ratio.
Does your site require interns to be drug tested?
Yes
No
Does your site require background checks?
Yes
No
Submit
Should be Empty: