University of Colorado
Skaggs School of Pharmacy and Pharmaceutical Sciences
University of Colorado Anschutz Medical Campus
Mail Stop C238|12850 E. Montview Blvd.
Aurora, CO 80045|(P) 303-724-2655 (F) 303-724-2658
Return to
SOP.Outreach@ucdenver.edu
New preceptor? Include CV/resume
APPE PRACTICE SITE SURVEY (2016-2017) - Advanced Pharmacy Practice Experience
Site name:
Site address:
City:
County:
State:
Zip code:
Country(if not USA):
Rotation type: Select the rotation type(s) below that most closely matches the experience you are offering.
AMBULATORY
Activities focused on providing patient care for one or more disease states and conditions through interactions with
non-hospitalized patients and health care teams in outpatient clinics. The pharmacist provides direct patient care
services with oversight by a prescriber or under collaborative drug therapy management protocols and has access
to and documents her/his activities in patients’ medical records.
Ambulatory – Multi-Disease State: Focus on a wide range of disease states and conditions (3 or more)
Ambulatory – Specialties: Focus on one or two disease states and conditions.
Please indicate one or two specialties below that will occupy the majority of student time. If more than 2
specialties are regularly covered on rotation please select “Ambulatory – Multi-Disease State” above.
% of student time in each area
Ambulatory - Anticoagulation
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Ambulatory - Cardiovascular
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Ambulatory - Endocrinology
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Ambulatory - Geriatrics
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Ambulatory - Home Infusion/Long Term Care
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Ambulatory - Neurology
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Ambulatory - Oncology
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Ambulatory - Other Specialty (please name)
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COMMUNITY PHARMACY
Activities focused on providing patient care in an outpatient/community setting through drug distribution and
counseling patients about medications and health-promotion and disease-prevention activities.
% of student time in each area
Community - Compounding
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Community - Disease State Management (DSM)*
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Community - Dispensing & Medication Systems Management
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Community - Health Promotion/Disease Prevention Activities
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Community - Immunizations
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Community - Management
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Community - Medication Therapy Management (MTM)**
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Community - Patient Counseling
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*Providing disease state and/or medication management care by appointment to patients who are referred by
other health care practitioners or to patients who request those services
**Medication therapy management services within the community pharmacy setting
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HEALTH-SYSTEM PHARMACY INPATIENT
Activities focused on providing patient care through interactions with hospitalized patients, health care
teams, and medication systems management.
% of student time in
each area
Health-System Inpatient - GENERAL PRACTICE
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Health-System Inpatient - INTERNAL MEDICINE
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Health-System Inpatient - ANTICOAGULATION
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Health-System Inpatient - CARDIOLOGY
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Health-System Inpatient - CRITICAL CARE
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Health-System Inpatient - EMERGENCY MEDICINE
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Health-System Inpatient - INFECTIOUS DISEASE
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Health-System Inpatient - LONG TERM CARE
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Health-System Inpatient - MEDICATION RECONCILIATION
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Health-System Inpatient - PEDIATRICS
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Health-System Inpatient - PSYCH
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Health-System Inpatient - OTHER Specialty (please name)
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ELECTIVE
Rotations other than the ambulatory, community and health-system inpatient rotations listed above.
% of student time in each area
Elective – Administration
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Elective – Drug Information
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Elective – Education
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Elective – Health-System Inpatient OPERATIONS*
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Elective – Industry/Wholesaler
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Elective – International
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Elective – Research
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Elective – Other (please name)
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*Drug distribution and other medication systems management within an inpatient setting.
If the distribution of rotation activities changes throughout the year please explain:
Rotation type or availability comments/clarifications?
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Primary Preceptor
Last Name:
First Name:
Job Title:
Degrees (please list all):
Certifications (please list all):
Pharmacist License Number(s) and State(s):
Pharmacist License Original Issue Date (approx):
First time CU preceptor? Yes or No
Phone(s):
Fax:
E-mail(s):
Residency Trained? Yes or No
Multiple years of residency/fellowship? Yes or No
Continuing pharmacy education (CPE) credits specifically from preceptor education/training
courses? Yes or No
# CPE Hours:
Currently participate in other activities with a School of Pharmacy, such as committees or the
new applicant interview process, facilitating classroom discussions, etc.? Yes or No
Number of years in current practice setting:
years
Engaged in scholarly activities/research? Yes or No
If so, please describe:
Involved in multidisciplinary committees/activities in addition to direct patient care? Yes or No
Experience precepting pharmacy residents? Yes or No
Engaged in any practice management responsibilities? (DUE, QA) Yes or No
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Secondary Preceptor
Last Name:
First Name:
Job Title:
Degrees (please list all):
Certifications (please list all):
Pharmacist License Number(s) and State(s):
Pharmacist License Original Issue Date (approx):
First time CU preceptor? Yes or No
Phone(s):
Fax:
E-mail(s):
Residency Trained? Yes or No
Multiple years of residency/fellowship? Yes or No
Continuing pharmacy education (CPE) credits specifically from preceptor education/training
courses? Yes or No
# CPE Hours:
Currently participate in other activities with a School of Pharmacy, such as committees or the
new applicant interview process, facilitating classroom discussions, etc.? Yes or No
Number of years in current practice setting:
years
Engaged in scholarly activities/research? Yes or No
If so, please describe:
Involved in multidisciplinary committees/activities in addition to direct patient care? Yes or No
Experience precepting pharmacy residents? Yes or No
Engaged in any practice management responsibilities? (DUE, QA) Yes or No
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Tertiary Preceptor
Last Name:
First Name:
Job Title:
Degrees (please list all):
Certifications (please list all):
Pharmacist License Original Issue Date (approx):
Licensed preceptor? Yes or No
First time CU preceptor? Yes or No
Phone(s):
Fax:
E-mail(s):
Residency Trained? Yes or No
Multiple years of residency/fellowship? Yes or No
Continuing pharmacy education (CPE) credits specifically from preceptor education/training
courses? Yes or No
# CPE Hours:
Currently participate in other activities with a School of Pharmacy, such as committees or the
new applicant interview process, facilitating classroom discussions, etc.? Yes or No
Number of years in current practice setting:
years
Engaged in scholarly activities/research? Yes or No
If so, please describe:
Involved in multidisciplinary committees/activities in addition to direct patient care? Yes or No
Experience precepting pharmacy residents? Yes or No
Engaged in any practice management responsibilities? (DUE, QA) Yes or No
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Which preceptors should be able to complete evaluations of students (if more than one
participates)?
Are you able to accommodate students who are not US citizens? Yes or No
Non-US citizen comments/clarifications?
CV/Resume:
In accordance with accreditation standards for American colleges and schools of pharmacy, all
preceptors are required to submit a copy of their CV/resume to the Office of Experiential Programs
Affiliation Agreement:
In accordance with accreditation standards for American colleges and schools of pharmacy, it is
school policy to have executed written affiliation agreements with all sites.
Pharmacy License:
If this rotation falls under the purview of a pharmacy license please enter it here:
Services provided and/or products sold:
Practice site demonstrates a strong commitment to health promotion and illness prevention
as reflected by the services provided and/or products sold (e.g., provision of health
screening, tobacco cessation counseling, immunizations; not stocking cigarettes and other
tobacco products)
Both services provided and products sold align with statement above.
Services provided align with statement above, but not products sold.
Products sold align with statement above, but not services provided.
Neither services provided nor products sold align with statement above.
Comments:
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General Practice Site Information
Narrative Description of Educational Activities: please use whatever space necessary to:
Describe the educational activities students can expect at the practice site. If applicable to your rotation,
consider including comment about the following:
Concomitant problems
Patient population and demographics
Pharmacy programs - e.g. ADR reporting program,
Anticoagulation, MTM, Pain Management, etc.)
Drug distribution activities
Committee work
Activities/Assignments - e.g. Accreditation,
Drug/Medication use evaluation, Financial
management, Legislative issues, Monograph
writing, Pharmacy workload, Protocol development,
research, etc.
Compounding
Presentations
Observed procedures
Identification/resolution of drug-related
problems (DRP)
Patient care rounds
Provide an overview of a typical day
List specific considerations - e.g. 1. Spanish
language skills are necessary, 2. Compounding
rotations may not be appropriate for pregnant
and breast-feeding students for concerns
regarding chemical exposure, etc.
How long has the site been taking students?
Does the site have internet access available to students for drug
information research?
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Years
Yes or No
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Ambulatory, Community and Inpatient Health-System Preceptors Only
Yes
No
Yes
No
Yes
No
Is this site affiliated with any pharmacy residency training programs?
Will students be given increasing patient care responsibility as they progress through the
rotation?
Will students complete pre-designed learning activities at selected times during the rotation?
Will students routinely be given opportunities to provide/deliver education to a group?
Ambulatory and Inpatient Health-System Preceptors Only
Will students have routine interactions with students/residents from other disciplines?
Does the site utilize electronic medical records?
Will students be able to participate in the progress note documentation process?
Will students have opportunity to attend weekly grand rounds/other specialized health care
meetings?
Will the student be exposed to specialty services such as IND work, formulary management,
CPOE/physician order entry, public health activities, etc?
If yes, describe
Are there any outside opportunities available to students? (procedures, education classes,
group patient visits, etc.)
If yes, describe
Will students be exposed to administrative aspects/P&T committee/regulatory functions?
Will the student have a designated work area with a dedicated computer?
Ambulatory Preceptors Only
Will students have access to the patient’s complete medical record?
How much student time will be spent on direct patient care? (0-100%, in 5% increments)
%
Will the student have routine direct patient interaction?
Will the student have routine direct interaction with other (non-pharmacist) providers?
Will students be exposed to performing physical assessments?
Are there electronic resources available for students to use on site?
Are there specialized opportunities/services, e.g. CDTM, MTM, kinetic services, pain
management?
If yes, describe
Will the student be exposed to any type of pharmacy reimbursement programs?
Are there institutional guidelines that guide decision making regarding appropriate
pharmacotherapy?
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Community Pharmacy Preceptors Only
Yes
Will students routinely provide direct patient communication/counseling?
Will students be compounding on a daily basis (excluding KBX/reconstitutions)?
Does this rotation site offer disease state management?
If yes, approximately how many patients are seen for DSM/week?
Does the site offer MTM services that the student will participate in?
If yes, approximately how many patients are seen for MTM/week?
Does this site provide any immunization delivery?
If yes, approximately how many patients are immunized/week?
Will the students be utilizing any point-of-care testing technology (2x/week or more)
If yes, describe
Will students have routine communications with outside providers? (i.e. several times/week)
Will students participate in any health promotion/disease prevention activities?
If yes, describe
Does this site have any contracted health screening opportunities?
Will the student be involved in OTC counseling (stepping outside the dispensary)
Is this pharmacy site affiliated with any hospital institutions?
Does this pharmacy utilize a central database that links several stores into one accessible
database?
Does the site utilize any automation that students may encounter?
If yes, describe
Will the student have access to a private consultation area?
Will the student have access to a semi-private consultation area?
Will this rotation offer any business/management perspectives of pharmacy to the students?
Will students be exposed to any type of bar coding system as part of the dispensing process?
Does the site have access to and utilize patients’ complete medical records (from the provider’s
office or hospital)
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No
Inpatient Health-System Preceptors Only
Yes
No
Average daily inpatient census for the hospital/health-system
Average number of patients cared for daily as part of this rotation
Will the student be given the opportunity to go on rounds?
If yes, how frequently? (# days/week 1-5)
Will a pharmacist or preceptor accompany the students on rounds?
If yes, how frequently? (# days/week 1-5)
Will the student provide direct patient communication/counseling on a routine basis?
Will students be exposed to the role of drug distribution?
If yes, what % of their time will be spent with this? 0-100%, in 10% increments
What % of time will the preceptor directly interact with students on average? (0-100%, in 10% increments)
Does this site have any specialized opportunities/services, such as CDTM, MTM, kinetic
services, pain management?
If yes, describe
Does this site provide opportunity for team-based direct patient care (i.e. providing education/
counseling together with other disciplines)
Does the site have the ability to document pharmacist interventions?
If yes, describe
Will students be exposed to the institution’s process for reporting identified med safety/ADRs?
Will students be exposed to hospital pharmacy operations (drug distribution/other centralized
services)?
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The University of Colorado is committed to equal employment opportunity and affirmative action.
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