HIV ePharmacotherapy Network - Preceptorship

Preceptorship

Residency

Fellowship

Certificate

Research

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University at Buffalo, the State University of New York School of Pharmacy and Pharmaceutical Sciences

Preceptorship - Apply Online

All individuals interested in the program must complete the application below and submit it with the required supporting documents. The program targets clinicians who wish to further develop their clinical practice expertise in the management of patients with HIV in acute or ambulatory care environments and who are practicing in an environment that supports the further growth and development of clinical activities. It is intended to provide exposure to an alternative model of HIV pharmacotherapy practice and collaboration with other providers in HIV pharmacotherapy.

Please fill out the short application form below and click "Submit Application".

Adobe Acrobat Icon A editable PDF version of this application, suitable for paper-submissions, is available here.

Demographics (All fields are required)
Last Name	First Name	Middle Name

Street Address	Apartment #

City	State	Zip

E-mail address	Phone	Fax

Employment Affiliation(s)
Institution	Title

Institution	Title

Current Practice Site (check all that apply)
	Acute Care / Inpatient Clinical Services	Outpatient Dispensing
	Ambulatory Clinic	Inpatient Dispensing
Other (please specify)

Number of active HIV+ patients

Responsibilities in current position (check all that apply)
	Decision-making regarding initiating ARVT(Antiretroviral Therapy)	Counseling on ARVT
	Routine pharmacotherapy assessments during patient's clinical visits	Evaluation of patients by appointment only
	Teaching (didactic) Pharmacy or medical students	Precepting: Pharmacy or medical students / interns / residents
Other (please specify)

Education
Institution Name	Year Graduated	Degree

Post-Graduate Training (Dates should be in the format mm/dd/yyyy)

Residency
Fellowship

Specialty Area

Site

Preceptor

From Date

To Date

Residency
Fellowship

Specialty Area

Site

Preceptor

From Date

To Date

Residency
Fellowship

Specialty Area

Site

Preceptor

From Date

To Date

Experience

Are you a Board-Certified Pharmacotherapy Specialist? Yes No

Specify area(s) of interest in clinical pharmacy practice:

Specify area(s), if any, of ongoing clinical pharmacy research:

Please mail or e-mail the following supporting documents to the address below:

A letter outlining your professional reasons for seeking this Preceptorship and how you would like to further develop clinical pharmacotherapy services in your practice setting.
A letter of support from your Medical Director, Program Manager, or Director of Pharmacy, indicating their support of your participation in the program and of your interest in further developing pharmaceutical care HIV services.
Curriculum Vitae

HIV Pharmacotherapy Preceptorship Program
Department of Pharmacy Practice
State University of New York at Buffalo
371 Cooke Hall
Buffalo, NY 14260

For more information, please e-mail Marsha M Nelson at mmnelson@acsu.buffalo.edu

Once the above application form and aforementioned supporting documents are received, your application will be complete.

Please direct any questions about the Preceptorship Program to Linda Catanzaro, Pharm.D. at lcat@adelphia.net or call 716-645-2828 ext. 276