Site Information Form
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Preceptor Completing Form *
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Site (include store number if applicable) *
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Site Address
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City *
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Are pharmacy residency or fellowship positions available at your site? If yes, please list areas.
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Patient populations served by your site (pediatrics, oncology, geriatric, etc.).
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Your site is best suited for what level of student (Introductory (P1, P2, P3) or Advanced (P4))?
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Is housing available for students? If yes, indicate costs and describe accommodations as well as contact person for housing.
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Prescriptions filled per week?
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Please provide information about site parking; is parking on site? Is there a fee? Is it secured?
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Site hours of operation
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What types of screenings are available at your site?
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