First Name
* must provide value
Last Name
* must provide value
NMS Match ID #
* must provide value
Rotation #1 Site Name/Location
(Include Business Name, City, State)
Rotation #1 Preceptor Name
Rotation #1 Type of Rotation
Rotation #1 - Did you spend > or = to 50% of your time on this rotation engaged in direct patient care activities (eg; rounding with a team, counseling patients, providing MTM services, taking medication histories)
Yes
No
Rotation #1 - Provide a brief description of the activities completed on rotation, interactions with preceptor (all day every day, part of each day, some days, etc), hours spent on rotation, types of patients you interacted with and were responsible for, common disease states treated, and any other information you think is pertinent.
Rotation #1 - Number of days you attended this rotation (do not include weekends or personal days you took off of rotation)
Type N/A if rotation is not yet completed
Rotation #1 - Average Number of Patients Followed on Inpatient Rotation.
If not an Inpatient rotation, type N/A
If rotation not yet complete, type To Be Completed
Rotation #2 Site Name/Location
(Include Business Name, City, State)
Rotation #2 Preceptor Name
Rotation #2 Type of Rotation
Rotation #2 - Did you spend > or = to 50% of your time on this rotation engaged in direct patient care activities (eg; rounding with a team, counseling patients, providing MTM services, taking medication histories)
Yes
No
Rotation #2 - Provide a brief description of the activities completed on rotation, interactions with preceptor (all day every day, part of each day, some days, etc), hours spent on rotation, types of patients you interacted with and were responsible for, common disease states treated, and any other information you think is pertinent.
Rotation #2 - Number of days you attended this rotation (do not include weekends or personal days you took off of rotation)
Type N/A if rotation is not yet completed
Rotation #2 - Average Number of Patients Followed on Inpatient Rotation.
If not an Inpatient rotation, type N/A
If rotation not yet complete, type To Be Completed
Rotation #3 Site Name/Location
(Include Business Name, City, State)
Rotation #3 Preceptor Name
Rotation #3 Type of Rotation
Rotation #3 - Did you spend > or = to 50% of your time on this rotation engaged in direct patient care activities (eg; rounding with a team, counseling patients, providing MTM services, taking medication histories)
Yes
No
Rotation #3 - Provide a brief description of the activities completed on rotation, interactions with preceptor (all day every day, part of each day, some days, etc), hours spent on rotation, types of patients you interacted with and were responsible for, common disease states treated, and any other information you think is pertinent.
Rotation #3 - Number of days you attended this rotation (do not include weekends or personal days you took off of rotation)
Type N/A if rotation is not yet completed
Rotation #3 - Average Number of Patients Followed on Inpatient Rotation.
If not an Inpatient rotation, type N/A
If rotation not yet complete, type To Be Completed
Rotation #4 Site Name/Location
(Include Business Name, City, State)
Rotation #4 Preceptor Name
Rotation #4 Type of Rotation
Rotation #4 - Did you spend > or = to 50% of your time on this rotation engaged in direct patient care activities (eg; rounding with a team, counseling patients, providing MTM services, taking medication histories)
Yes
No
N/A, (if rotation incomplete)
Rotation #4 - Provide a brief description of the activities completed on rotation, interactions with preceptor (all day every day, part of each day, some days, etc), hours spent on rotation, types of patients you interacted with and were responsible for, common disease states treated, and any other information you think is pertinent.
Rotation #4 - Number of days you attended this rotation (do not include weekends or personal days you took off of rotation)
Type N/A if rotation is not yet completed
Rotation #4 - Average Number of Patients Followed on Inpatient Rotation.
If not an Inpatient rotation, type N/A
If rotation not yet complete, type To Be Completed
Rotation #5 Site Name/Location
(Include Business Name, City, State)
Rotation #5 Preceptor Name
Rotation #5 Type of Rotation
Rotation #5 - Did you spend > or = to 50% of your time on this rotation engaged in direct patient care activities (eg; rounding with a team, counseling patients, providing MTM services, taking medication histories)
Yes
No
N/A (if rotation incomplete)
Rotation #5 - Provide a brief description of the activities completed on rotation, interactions with preceptor (all day every day, part of each day, some days, etc), hours spent on rotation, types of patients you interacted with and were responsible for, common disease states treated, and any other information you think is pertinent.
Rotation #5 - Number of days you attended this rotation (do not include weekends or personal days you took off of rotation)
Type N/A if rotation is not yet completed
Rotation #5 - Average Number of Patients Followed on Inpatient Rotation.
If not an Inpatient rotation, type N/A
If rotation not yet complete, type To Be Completed
Rotation #6 Site Name/Location
(Include Business Name, City, State)
Rotation #6 Preceptor Name
Rotation #6 Type of Rotation
Rotation #6 - Did you spend > or = to 50% of your time on this rotation engaged in direct patient care activities (eg; rounding with a team, counseling patients, providing MTM services, taking medication histories)
Yes
No
N/A, (if rotation incomplete)
Rotation #6 - Provide a brief description of the activities completed on rotation, interactions with preceptor (all day every day, part of each day, some days, etc), hours spent on rotation, types of patients you interacted with and were responsible for, common disease states treated, and any other information you think is pertinent.
Rotation #6 - Number of days you attended this rotation (do not include weekends or personal days you took off of rotation)
Type N/A if rotation is not yet completed
Rotation #6 - Average Number of Patients Followed on Inpatient Rotation.
If not an Inpatient rotation, type N/A
If rotation not yet complete, type To Be Completed
Rotation #7 Site Name/Location
(Include Business Name, City, State)
Rotation #7 Preceptor Name
Rotation #7 Type of Rotation
Rotation #7 - Did you spend > or = to 50% of your time on this rotation engaged in direct patient care activities (eg; rounding with a team, counseling patients, providing MTM services, taking medication histories)
Yes
No
N/A, (if rotation incomplete)
Rotation #7 - Provide a brief description of the activities completed on rotation, interactions with preceptor (all day every day, part of each day, some days, etc), hours spent on rotation, types of patients you interacted with and were responsible for, common disease states treated, and any other information you think is pertinent.
Rotation #7 - Number of days you attended this rotation (do not include weekends or personal days you took off of rotation)
Type N/A if rotation is not yet completed
Rotation #7 - Average Number of Patients Followed on Inpatient Rotation.
If not an Inpatient rotation, type N/A
If rotation not yet complete, type To Be Completed
Rotation #8 Site Name/Location
(Include Business Name, City, State)
Rotation #8 Preceptor Name
Rotation #8 Type of Rotation
Rotation #8 - Did you spend > or = to 50% of your time on this rotation engaged in direct patient care activities (eg; rounding with a team, counseling patients, providing MTM services, taking medication histories)
Yes
No
N/A, (if rotation incomplete)
Rotation #8 - Provide a brief description of the activities completed on rotation, interactions with preceptor (all day every day, part of each day, some days, etc), hours spent on rotation, types of patients you interacted with and were responsible for, common disease states treated, and any other information you think is pertinent.
Rotation #8 - Number of days you attended this rotation (do not include weekends or personal days you took off of rotation)
Type N/A if rotation is not yet completed
Rotation #8 - Average Number of Patients Followed on Inpatient Rotation.
If not an Inpatient rotation, type N/A
If rotation not yet complete, type To Be Completed
Rotation #9 Site Name/Location
(Include Business Name, City, State)
Rotation #9 Preceptor Name
Rotation #9 Type of Rotation
Rotation #9 - Did you spend > or = to 50% of your time on this rotation engaged in direct patient care activities (eg; rounding with a team, counseling patients, providing MTM services, taking medication histories)
Yes
No
N/A, (if rotation incomplete)
Rotation #9 - Provide a brief description of the activities completed on rotation, interactions with preceptor (all day every day, part of each day, some days, etc), hours spent on rotation, types of patients you interacted with and were responsible for, common disease states treated, and any other information you think is pertinent.
Rotation #9 - Number of days you attended this rotation (do not include weekends or personal days you took off of rotation)
Type N/A if rotation is not yet completed
Rotation #9 - Average Number of Patients Followed on Inpatient Rotation.
If not an Inpatient rotation, type N/A
If rotation not yet complete, type To Be Completed
Rotation #10 Site Name/Location
(Include Business Name, City, State)
Rotation #10 Preceptor Name
Rotation #10 Type of Rotation
Rotation #10 - Did you spend > or = to 50% of your time on this rotation engaged in direct patient care activities (eg; rounding with a team, counseling patients, providing MTM services, taking medication histories)
Yes
No
N/A, (if rotation incomplete)
Rotation #10 - Provide a brief description of the activities completed on rotation, interactions with preceptor (all day every day, part of each day, some days, etc), hours spent on rotation, types of patients you interacted with and were responsible for, common disease states treated, and any other information you think is pertinent.
Rotation #10 - Number of days you attended this rotation (do not include weekends or personal days you took off of rotation)
Type N/A if rotation is not yet completed
Rotation #10 - Average Number of Patients Followed on Inpatient Rotation.
If not an Inpatient rotation, type N/A
If rotation not yet complete, type To Be Completed
Rotation #11 Site Name/Location
(Include Business Name, City, State)
Rotation #11 Preceptor Name
Rotation #11 Type of Rotation
Rotation #11 - Did you spend > or = to 50% of your time on this rotation engaged in direct patient care activities (eg; rounding with a team, counseling patients, providing MTM services, taking medication histories)
Yes
No
N/A, (if rotation incomplete)
Rotation #11 - Provide a brief description of the activities completed on rotation, interactions with preceptor (all day every day, part of each day, some days, etc), hours spent on rotation, types of patients you interacted with and were responsible for, common disease states treated, and any other information you think is pertinent.
Rotation #11 - Number of days you attended this rotation (do not include weekends or personal days you took off of rotation)
Type N/A if rotation is not yet completed
Rotation #11 - Average Number of Patients Followed on Inpatient Rotation.
If not an Inpatient rotation, type N/A
If rotation not yet complete, type To Be Completed
Rotation #12 Site Name/Location
(Include Business Name, City, State)
Rotation #12 Preceptor Name
Rotation #12 Type of Rotation
Rotation #12 - Did you spend > or = to 50% of your time on this rotation engaged in direct patient care activities (eg; rounding with a team, counseling patients, providing MTM services, taking medication histories)
Yes
No
N/A, (if rotation incomplete)
Rotation #12 - Provide a brief description of the activities completed on rotation, interactions with preceptor (all day every day, part of each day, some days, etc), hours spent on rotation, types of patients you interacted with and were responsible for, common disease states treated, and any other information you think is pertinent.
Rotation #12 - Number of days you attended this rotation (do not include weekends or personal days you took off of rotation)
Type N/A if rotation is not yet completed
Rotation #12 - Average Number of Patients Followed on Inpatient Rotation.
If not an Inpatient rotation, type N/A
If rotation not yet complete, type To Be Completed
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