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The University of Kansas - Non-Traditional Pharm.D Program
Non-Traditional Clerkship Site Agreement - Signature Form for Online Proposal

REQUIRED before Proposal will be considered complete. Print this form directly out of your browser window, complete, sign and have your local preceptor sign. Fax to Prof. Dahm at 913.393.9848

Student:

_________________________________________________

Student Signature:

_________________________________________________

Clerkship Site:

_________________________________________________

Preceptor Name:

_________________________________________________

Dear Preceptor:

The goal of each NTPD clerkship is to provide the student access to experiences that will improve their clinical skills and their ability to provide advanced pharmaceutical care. Your input, as a preceptor, is vital in achieving this. Thank you for your participation!

By signing this agreement you are acknowledging that you have reviewed the course competencies and objectives the student has completed and you agree with the student's plan to attain these goals and competencies in this site. To accomplish this you are also agreeing to provide the student:

access to patients

access to patient charts

access to lab data

other resources and expertise you deem necessary to make this clerkship a valuable active learning experience

review and grading of one 20-30 minute presentation to yourself and at least 2 other colleagues in your clinical site.

In addition:

Preceptor will evaluate/assess the student using the NTPD evaluation form

Preceptor will provide other information or experiences you feel are necessary to provide a strong clinical foundation for this student.

No payment is made to the clerkship site

Do you feel the proposed time to meet the clerkship goals is adequate?

____________________________________________________________________

If not, how should the student adjust their expectations?

____________________________________________________________________

I agree to precept this student and will provide a learning environment conducive with accomplishing the clerkship goals outlined.

NTPD Preceptor:

_________________________________________________

Date:

_________________________________________________

Student:	_________________________________________________
Student Signature:	_________________________________________________
Clerkship Site:	_________________________________________________
Preceptor Name:	_________________________________________________

Dear Preceptor: The goal of each NTPD clerkship is to provide the student access to experiences that will improve their clinical skills and their ability to provide advanced pharmaceutical care. Your input, as a preceptor, is vital in achieving this. Thank you for your participation! By signing this agreement you are acknowledging that you have reviewed the course competencies and objectives the student has completed and you agree with the student's plan to attain these goals and competencies in this site. To accomplish this you are also agreeing to provide the student: access to patients access to patient charts access to lab data other resources and expertise you deem necessary to make this clerkship a valuable active learning experience review and grading of one 20-30 minute presentation to yourself and at least 2 other colleagues in your clinical site. In addition: Preceptor will evaluate/assess the student using the NTPD evaluation form Preceptor will provide other information or experiences you feel are necessary to provide a strong clinical foundation for this student. No payment is made to the clerkship site
Do you feel the proposed time to meet the clerkship goals is adequate?
____________________________________________________________________
If not, how should the student adjust their expectations?
____________________________________________________________________

I agree to precept this student and will provide a learning environment conducive with accomplishing the clerkship goals outlined.
NTPD Preceptor:	_________________________________________________
Date:	_________________________________________________