Creighton University New Precptor/Site Request

Creighton University School of Pharmacy & Health Professions

Thank you for your interest in becoming a preceptor for our pharmacy students. Please fill in all of the requested information below.

Once you submit the information, someone from the Experiential Office will be in touch with you to discuss your potential experiential training opportunities at your site.

I. Basic Preceptor/Contact and Site Information

Are you the Coordinator or do you serve in both roles at your site?

Please check all that apply.

Coordinator ((student/experiential, administrative or clinical)
Preceptor
Other

Your Information

First Name:

Middle Initial

Last Name:

Gender:

Position Title

Work Phone # (###-###-####):

Cell # (###-###-####)

Fax # (###-###-####):

E-mail Address:

Site Information

Site Name:

Street Address:

City:

State:

Zip Code:

II. Additional Information for You

Preferred Method of Contact

Phone
Email
Cell

School/Licensure

Pharmacy Degree(s): (Pharm.D., B.S., M.S., MBA, PhD...)

Institution and Year of Pharmacy Degree(s):

Primary Pharmacy Licensure State and License #:

Secondary Pharmacy Licensure State and License #:

Residency and/or Fellowship?

Yes
No

If yes, please list institution and year(s):

Significant Past Work Experiences:

Specialty Certifications:

Professional Organizations:

Please comment on your availability to take future Creighton students: (e.g., available this student only, limited dates, would consider future students, etc.)

III. Practice Setting and Rotation Information

Type of practice setting:

Community
Hospital
Clinic
Other

Is your rotation - In Person, Hybrid, Remote?

Fully In Person
Hybrid
Fully Remote

If you selected Hybrid above, please list your approximate schedule.
For Example - M, W, F - In Person, T, Th - Remote

Type(s) of pharmacy services provided:

Distributive
Clinical
Other

Description of pharmacy services provided:

Typical patient load or volume:

#Scripts/day:

#Patients/day

Hospital Census

Other:

Typical patient population: (e.g., gender, age, ethnicity, disease states):

Type of APPEs offered at this site.

Please select ALL that apply by holding down your Control key and clicking on the APPE type

To select multiple options in a row, click and drag your mouse or hold down Shift when selecting. To select non-sequential options, hold down Control (on a PC) or Command (on a Mac) when clicking. To deselect an option, hold down Control or Command and click on a selected option.

Daily activities, projects, and assignments required of the students while on this rotation:

Please list all preceptors willing to precept Creighton University students at your site:

Please include the following information:
Name, Credentials, Position Title, work phone, email address and pharmacist license number (if available)

Students are expected to be at the site full-time (40 hrs/wk x 5 wks). How much time do you expect to spend with the student? (Anticipated hours per week)

Creighton encourages preceptors to provide verbal feedback throughout the APPE and requires a formal evaluation at mid-point and at the end of the APPE. Are you willing to provide this feedback and complete these evaluations?

Yes
No

Does the student have access to drug information references or a library?

Yes
No

Does the student have access to patient information?

Yes
No

Does the student have an opportunity to interact with or counsel patients?

Yes
No

Have you taken pharmacy students for APPEs before?

Yes. Please list which schools and when students taken
No

Does your site require payment to take a student? If yes, please indicate amount?

Yes
No

IV. Miscellaneous Information

This request is for Advanced Pharmacy Practice Experience (APPE). Do you also offer or are you interested in providing Introductory Pharmacy Practice Experiences (IPPEs) to students?

Information helpful to our Office for future scheduling purposes is listed. Please check all preferences that apply.

Student may contact Site (during planning process)
OEE only to contact Site (we only want to communicate with the school)
First come, First served
Local schools given priority and scheduled first

Why do you choose to serve as a preceptor for students?

Please enter any questions or comments you may have.

Please tell us how you found this form:

I was asked to complete this by:
I found the link on web page
Other, please explain:

Acute Care
Ambulatory
Cardiology
Community
Community Management
Compounding
Critical Care
Drug Information
Emergency Medicine
Home Infusion
Hospital
Hospital Management
Industry
Infectious Disease
Informatics
Long Term Care
Managed Care
Medication Safety
MTM
Neurology
Nuclear
Oncology
Pediatrics
Poison
Psychiatry
Research
Transitions of Care
Transplant
Veterinary