Forms

Students

• Out-of-Program Rotation Request Form
• Special Studies Form (PHMY 539, APEX 424, APEX 428, APPC 490) (PDF, Word format)
  
• Preceptor of the Year Nomination Form

Student Liability Insurance

Insurance is provided by the Healthcare Providers Service Organization free with APhA-ASP membership in the fourth year beginning on May 1st. Additional paperwork is not required for the fourth year. Certificates of coverage are emailed to the APhA-ASP chapter advisor. There is a fee for coverage for first-, second-, and third-year students.

• Pharmacist Mutual Insurance Company Brochure
  

Forms for Specific Rotations

Food and Drug Administration

• Declaration for Federal Employment
• E-QIP Initiation Form
• Volunteer Program for Students Form
  

Giant

• Confidentiality Statement

Kaiser Permanente

• HC Form
• Confidentiality Agreement
• Student Inquiry Form

Malcolm Grow Medical Center

• Training Addendum
• Fingerprint/Background Check Instructions
• Fingerprint/Brackground Check Request Letter

MedStar Sites (Franklin Square Hospital, Good Samaritan Hospital, Harbor Hospital, Montgomery General Hospital, National Rehabilitation Hospital, St. Mary's Hospital, Union Memorial Hospital)

• Background Check Instructions (PreCheck)

St. Joseph's Medical Center

• Background Check Instructions (PreCheck)

VA Medical Center

• VA Information Security & Privacy Training Modules Directions
• National Rules of Behavior

Washington County Hospital

• Confidentiality Agreement
• Immunizations
• Liability Waiver
• Student Request Form

For New Preceptors

To become a preceptor, please complete an application, an affiliation agreement, and a site information survey. Please contact the ELP office to verify if an affiliation agreement and site survey are already in place.

• Preceptor Application
• Standard Affiliation Agreement
• Institutional Site Information Survey
• Community/Other Site Information Survey