Site Profile Form - FAO UNC Eshelman School of Pharmacy

Today's Date*

year/month/date

Name*

E-mail*

Name of Practice Site*

Site Address*

Site Telephone (general hospital operator)

Site Telephone (pharmacy)

Site Fax

Does site have internet and email access?*

Yes
No

URL or website address of site

Name of Primary Preceptor*

The primary preceptor is the liaison between the UNC School of Pharmacy/AHEC and the practice site who takes administrative, supervisory responsibility for the students at the site, including student performance evaluation.

Name of Other Preceptors

All preceptors are recognized by the School of Pharmacy as meeting certain established standards and criteria to participate in the educational process of pharmacy students. They must serve as teachers, role models, and mentors for students and be committed to the support and advancement of the profession of pharmacy. To be listed as a preceptor, a pharmacist must be responsible for immediately precepting the student for the majority of their experience and is responsible for the majority of their clerkship. Additionally, all preceptors must complete the required online training program to attain or maintain preceptor status. (See criteria for Excellence in Experiential Education).

Hours of Operation

Weekdays

Holidays

Saturday

Sunday

Collaboration with other healthcare professionals; Personnel with whom student will work*

(Check all that apply)

MD
PA
NP
Social Worker
Nutritionist
Other

If others, specify:

Describe use of technicians*

Does your site offer inter-professional education opportunities? If so, please describe.

The Accreditation Council For Pharmacy Education makes the following statement about inter-professional team education in the 2016 standards:
“To advance collaboration and quality of patient care, the didactic and experiential curricula include opportunities for students to learn about, from, and with other members of the inter-professional healthcare team.”

Type of Site*

(check all that apply)

Patient Types*

(check all that apply)

Acute
Ambulatory
Extended Care
N/A

Describe common disease states of your patient population:*

Number of beds in institution, if applicable

Approximate number of orders/prescriptions filled/day, if applicable

Does the pharmacy use a regular and systematic procedure for things as:

Reviewing stock levels*

Yes
No

Bid purchasing system*

Yes
No

Determining turnover of stock for various sections of the pharmacy*

Yes
No

Does the pharmacy belong to a buying group?*

Yes
No

Does the pharmacy have a prime vendor buying system?*

Yes
No

Other (specify):

Distribution Systems*

(check all that apply)

If compounding:

list #/week

If satelites:

list #

IV Admixture Programs*

Yes
No
Not applicable to this site

Computer Supported

Yes
No

TPN compounding

Yes
No

Approximate # Units/Day

Clinical/Professional Services*

(check all that apply)

If formulary system:

open
closed

If nursing home:

# of facilities served/#of beds

Does the site use a multidisciplinary approach to training students?*

Yes
No

Does the site/preceptor provide advanced pharmaceutical care to their patients?*

Yes
No

Does the site have accreditation for residencies?*

Yes
No

Does the site accept students from other pharmacy schools?*

Yes
No

Do you provide a work/study area for the student?*

Yes
No

Do you provide an area for students to store belongings?*

Yes
No

Does the site have written policies and procedures covering various professional, personnel and management practices including an exposure control plan?*

Yes
No

Does the site require drug screens for students?*

Yes
No

Does the site require drug screens for students?*

Yes
No

Does the site require a background check for students?*

Yes
No

In anticipating greater diversity in students in pharmacy, are you able to accomodate a student with a mobility/physical impairment in your practice site?*

Please contact kim_leadon@unc.edu if you would like a review of your facility for purposes of determining accessibility.

Yes
No

Provide a brief site description.*

(will be posted to the school's website for students to access)

Which references are available for use in your site? (please check those available)

Drug Product & General Information

Facts and Comparisons
American Hospital Formulary Service Drug Information
Handbook of Non-Prescription Drugs
A medical dictionary
Physician's Desk Reference
Other

Product Formulation

Remington's Pharmaceutical Sciences
United State's Pharmacopeia and national Formulary
Handbook of Injectable Drugs (Trissel)
The (Martindale) Extra Pharmacopoeia
The Merck Index
Other

Pharmacology

Pharmacological Basis of Therapeutics (Goodman and Gilman)
Medical Pharmacology (Goth)
Other

Therapeutic

Applied Therapeutics (Koda-Kimble)
Drug Interactions by Hansten; USP DI from SP; or Drug Interaction Facts from Facts and Comparisons
A textbook of medicine
Patient education and counseling guide
Other

Toxicology

Clinical Toxicology of Comercial Products
Handbook of Poisoning
Other general toxicology references, e.e., drug overdose text

Computerized Information Services

Identidex
Drugdex
Poisondex
Computerized literature retrieval service (e.g. Medline access)
Natural medicines Comprehensive Database
Other

If you selected other for any type of reference, please specify: