PHARMACY CLERKSHIP APPLICATION
SouthEast Alaska Regional Health Consortium
Mt. Edgecumbe Hospital

STUDENT PROFILE

Name (Last, First, M.I.) : ____________________________________________________

Home Address: ___________________________________________________________

City, State, Zip: ___________________________________________________________

Phone: ___________________________FAX (if available):_________________________

Campus Address:____________________________________________________
(If different)
City, State, Zip:______________________________________________________

Phone:________________________FAX (if available):_______________________

e-mail: ___________________________________________________________________

Date of Birth: _______________________ Place of Birth: ___________________________

Social Security: ____________________________________________________________

Please circle one: [Male] [Female]

U.S. Citizen? Yes ___No___ If no, please explain: ________________________________

What date will you be available?

First choice: ___________________________ Second choice: _______________________

 

Academic Experience (Chronological order, commencing with high school)
Name and Location of Institution ---- Dates Attended ----- Degree and Date

____________________________ ____________________ ___________________

____________________________ ____________________ ___________________

____________________________ ____________________ ___________________

____________________________ ____________________ ___________________

Employment (Chronological order commencing with high school)
Name of Employer & City ---------------------- Dates -----------------Position

__________________________________ ____________ ____________________

__________________________________ ____________ ____________________

__________________________________ ____________ ____________________

__________________________________ ____________ ____________________

Summary of Professional Experience (months):

Community Pharmacy: (Full time) _____________ (Part time) _______________

Hospital Pharmacy: (Full time) ______________ (Part time) ________________

Other, explain ________________________________________________________

 

How would you judge your experience at this point in the following areas?
(Please circle. 0 = none, 4 = extensive)

0 1 2 3 4 Dispensing
0 1 2 3 4 Compounding
0 1 2 3 4 O.T.C. Drugs
0 1 2 3 4 Patient Contact
0 1 2 3 4 Physician Contact (Personal) (Phone)
0 1 2 3 4 Patient Record Systems
0 1 2 3 4 Ordering and Receiving Stock
0 1 2 3 4 Medical and Surgical Accessories
0 1 2 3 4 Drug Information
0 1 2 3 4 Manufacturing or Bulk Compounding
0 1 2 3 4 Narcotic and Manufacturing Control
0 1 2 3 4 Intravenous Solutions

 

Using the above activities as a guide., briefly indicate what experience you think would benefit you most:

_____________________________________________________________________

_____________________________________________________________________

_____________________________________________________________________

_____________________________________________________________________

What organizations have you been involved in? (Student, professional, social. Include offices held and major committees.)

_____________________________________________________________________

_____________________________________________________________________

_____________________________________________________________________

_____________________________________________________________________

What hobbies or out-of-school interests do you have?

_____________________________________________________________________

_____________________________________________________________________

_____________________________________________________________________

Please list the non-pharmacy school and social study courses you have taken:

_____________________________________________________________________

_____________________________________________________________________

_____________________________________________________________________

Include an official copy of your transcript through June of your application year (3/5 or 4/6) of your program.

Three letters of recommendation are required for your application to be complete. One should be from your off campus coordinator giving an evaluation of you for the clerkship program, a letter of recommendation from one of your professors and one from an individual who you have had as a preceptor for internship hours. If you have not completed any internship hours by the time of applying, the letter can be from someone who employed you.

1. Name of Coordinator: _________________________________________________

Phone : _________________________________

2. Name of Professor: ___________________________________________________

3. Name of Preceptor/Employer: ___________________________________________

 

The following five questions should be answered and submitted with the application form.

1. How do you plan on using your pharmacy education after graduation? Explain.

2. What do you see as the one main issue facing pharmacy and/or health care in general over the next ten years. Explain.

3. How will completing a pharmacy clerkship with Mt. Edgecumbe Hospital help you in obtaining your professional goals? Explain.

4. Describe your concepts of Alaska.

5. In completing your intern hours to date, explain your practical experiences. What have you enjoyed the most and least? If you have not completed any intern hours prior to applying, pick a work experience and explain in the same manner.

Please return completed form to:

Mary E. Mackey, PharmD, BCPS
Clinical Pharmacist
Pharmacy Student Externship Coordinator
LCDR, United States Public Health Service
Mt. Edgecumbe Hospital
222 Tongass Dr.
Sitka, AK 99835

(907) 966-2411 ext 3263
e-mail: mmackey@searhc.org
WEB: http://puffin.ptialaska.net/~pharmacy

updated 7-18-13