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Pharmacist

Information

Name *

Last 4 digits of SSN *

Phone *

Email *

Proficiency Scale

1 = No Experience

2 = Need Training

3 = Able to perform with supervision

4 = Able to perform independently

Practice Settings/Experience

Academia *

Ambulatory Care *

Clinic *

Compounding *

Consulting *

Correctional Facility (Jail) *

Diabetes *

Drug Information *

Formulary Management *

Geriatrics *

Home Health *

Home Infusion *

Hospital Inpatient *

Hospital Outpatient *

Infectious Disease *

Long Term Care (LTC) *

Mail Order *

Military/Government/VA *

Nuclear *

Oncology *

Pain Management *

Pediatrics *

Pharmaceutical Research *

Pharmaceutical Sales *

Pharmacy Benefits Management (PBM) *

Poison Control *

Psychiatric Patient Management *

Public Health *

Renal Patient Management *

Retail Chain *

Retail Independent *

Sub-Acute Care *

Veterinary *

Other: *

Pharmacy Software Systems

Etreby *

HBS *

JASRx *

McKesson 3PM *

McKesson Pharmserv *

Meditech *

NDC *

OPUS ISM *

OSCOR *

PDX *

PharmNet *

Pharmtrak *

PROScript 2000 *

QS1 *

Renlar *

Rescot Omni-DX *

Rx-Link *

Speed Script *

TechRx *

WinPharm *

Other: *

Automation

Accumed/Baker Cells *

BAXA Rapid-Fill (ASF) *

BAXA Repeater Pump *

Baxter *

Baxter AUTOMIX Compounder *

Baxter MICROMIX Compounder *

Kirby Lester *

McKesson AcuDose-Rx *

McKesson Baker Scale *

McKesson IntelliShelf-Rx *

McKesson MedCarousel *

McKesson ROBOT Rx *

McKesson PACMED *

MTS Automated Sealers *

MTS Prepackaging *

Parata PACMED *

Parata RDS *

Parata APM *

PharmASSIST RDS ROBOTx *

PharmASSIST ROBOTx *

PharmASSIST SmartCabinet *

PharmASSIST SmartScale *

Pyxis *

Other: *

Disease State Management

AIDS/HIV *

Anticoagulation *

Asthma *

Cardiovascular Disease *

Chemotherapy *

Cystic Fibrosis *

Depression *

Diabetes *

Dyslipidemia *

Hormone Replacement Therapy *

Hypertension *

Osteoporosis *

Pain Management *

Smoking Cessation *

Transplant *

Other: *

Age Specific Competencies

Infant (Birth - 1 year) *

Preschooler (ages 2-5 years) *

Childhood (ages 6-12 years) *

Adolescents (ages 13-21 years) *

Young Adults (ages 22-39 years) *

Adults (ages 40-64 years) *

Older Adults (ages 65-79 years) *

Elderly (ages 80+ years) *

Pharmacokinetic Dosing of

Aminoglycosides *

Anticoagulation *

Digoxin *

Lithium *

Theophylline *

Vancomycin *

Other: *

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