USC New Preceptor Form
Please complete the following:
Personal Information:
First Name
Last Name
Other names used (i.e. former names, maiden name, preferred name, nickname, etc.)
Title
PharmD
RPh
PhD
MD
Mr.
Mrs.
Ms.
Other
If Other is selected, please type in the title below:
Email
Cell Number
Work Number
Site Name
Please include store number if applicable, otherwise type in N/A
Site/Business Address
City
State
Zip Code
Fax Number
Preferred Method of Contact
Job Title/Role
Department
Practitioner License # (i.e. CA12345) if not applicable, type N/A
Practitioner License E
x
piration Date
USC School of Pharmacy Graduate?
Yes
No
USC graduation year (type NA if this does not apply)
Have you precepted students before?
Yes
No
If yes, which schools do you currently precept for?
Please select the course(s) you are interested in teaching (select all that apply):
Introductory Pharmacy Practice Experience (IPPE P1-P3) Courses
IPPE Courses Interested in Teaching (Select all that apply)
Community
Institutional (Health-Systems)
Elective
Not sure - would like to discuss options with the PEP Office
Advanced Pharmacy Practice Experience (APPE P3-P4) Courses
APPE Courses Interested in Teaching (Select all that apply)
PHRD 701 Acute Care Clinical/Medicine
PHRD 704 Primary Care/Ambulatory Care
PHRD 705 Community Pharmacy Practice
PHRD 714 Nuclear Pharmacy
PHRD 718 Hospital Practice/Health Systems Pharmacy
PHRD 725 International Pharmacy Practice Experience
PHRD 731 Advanced Geriatrics
PHRD 738 Pharmaceutical Industry
PHRD 750 Advanced Pharmacy Practice (Patient Care) Elective
PHRD 751 Non-traditional (Non-patient care) Advanced Pharmacy Practice Elective
Not sure - would like to discuss options with the PEP office
Do you have a syllabus for the course you'd like to offer?
Yes (please upload a copy of your current syllabus below)
No, I'd like the PEP office to send me a template
Please upload a copy of your current CV or resume below
Contact Information