Aurora, CO 80045 Mail Stop (C238-V20) - Denver, Colorado€¦ · An updated CV or resume is required to complete the paperwork. Immunization Training (submit prior to APPE rotations

Distance Degrees and Programs Office Pharmacy & Pharmaceutical Sciences Bldg. 12850 E. Montview Blvd., Room V20-1116 Aurora, CO 80045 Mail Stop (C238-V20) 303-724-3582 office 303-724-3732 fax [email protected] [email protected] www.ucdenver.edu/pharmacy

Immunization and Certification Requirements

The University of Colorado mandates all students in health care professions whose training includes clinical settings and patient contact complete standard immunization requirements. Students enrolled in the North American-Trained PharmD (NTPD) Program and International Trained PharmD (ITPD) Program will have assignments throughout their didactic coursework and rotations which will require direct patient interaction. As such, all students will complete immunization and certification requirements as listed in this document and it the student’s responsibility to maintain the requirements throughout their enrollment in the program. Failure to adhere to the deadlines listed below will result in a hold placed on the student’s account, preventing the student from registering in future courses, planning and/or beginning rotations.

Upon Admission – See Pages 2-3

o ITPD Students – Students will complete all the requirements before starting their Live Summer Session I.

o NTPD Students – Students admitted for the 2017 spring semester will have six weeks from the start of the fall semester to submit their immunization and certification requirements. Therefore, the deadline for students admitted for the 2017 spring semester is Wednesday, March 1. Students who do not meet this deadline will have an administrative hold placed on their account. The hold prevents students registering for courses in an upcoming semester, and the hold will be removed once the DDP Office receives the immunization and certification requirements.

Prior to Rotations – Introductory and Advance Pharmacy Practice Experiences (IPPEs and APPEs) – See Pages 2-6

o All Students – All requirements must be updated the semester prior to the rotation start date and remain current throughout the remainder of the rotation. Saturday, October 1 is the deadline for students to update to their requirements if the student is starting a rotation during the 2017 spring semester. Wednesday, March 1 is the deadline for students to update to their requirements if the students is starting a rotation during the 2017 summer semester.

Students will collect and upload the requirements, except for the criminal background check, into E*Value. Please contact the Distance Degrees and Programs Office ([email protected] for NTPD students or [email protected] for ITPD students) if you cannot access your E*Value account. Immunization and Certification Requirements - Complete at Admission and Prior to Rotations

Criminal Background Check o Students Residing in the United States – You’ll fill out and return to the DDP

Office the Background Check Release form and the Address Verification form.

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o Students Residing in Canada – You’ll fill out and return to the DDP Office the Background Check Release form, the Canadian Form, and the Address Verification form.

o Students Residing outside the United States and Canada – You’ll fill out and

return to the DDP Office the Background Check Release form and the Address Verification form.

o The DDP Office will contact you to confirm the cost of the background check. You

may view current costs as listed on the tuition and fees website page.

o Note: Students with any arrest records or convictions, please follow the Student Ethics and Conduct Code policy and submit the paperwork underneath Appendix C.

Immunizations

o Complete and return the attached SOP Student Immunization Form signed by you and your medical provider.

o You’ll submit the supporting documentation for any lab results, such as titers done in lieu of immunization, or the signed form to meet the requirements. Ministry of health letters are not considered acceptable forms of documentation unless provided in addition to the signed immunization form.

o We accept serum titer results indicating immunity in lieu of being revaccinated if

childhood vaccination records are not readily available.

o NOTE: Please read the specific instructions on page two of the SOP Student Immunization Form for:

Measles, Mumps, Rubella (MMR) Hepatitis B Polio Tuberculin Skin Test Varicella

HIPAA and Bloodborne Pathogens (BBP) Exams

HIPAA & Security – Retake annually HIPAA & Privacy – Retake annually Bloodborne Pathogens (BBP) – Retake annually

o To complete your HIPAA and BBP requirements, you will utilize the online training offered by Pharmacist’s Letter and by following the steps listed below:

You will create a student account with Pharmacist’s Letter to complete the online training.

If you already have a separate Pharmacist’s Letter account, you will need to set up a student account in order for the Skaggs School of Pharmacy and Pharmaceutical Sciences to track your progress as a student.

You’ll create your student account at www.studentpharmacists.com. When creating your account, list your first and last name on record with the

Skaggs School of Pharmacy and Pharmaceutical Sciences and your UCDenver email address and anticipated graduation date.

After you create your account, Pharmacist’s Letter will connect you to the online training courses and corresponding exams within 24-48 hours. You will need to check your account again to see if you are connected to the courses and exams. Take only the full course. Do not take any courses

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labeled refresher. Once you complete the courses and receive a 90% or above on each of the

exams, you’ll print out a certificate confirming your passing grade and upload the certificate into E*Value.

If you have problems accessing the website or creating your account, you’ll contact Pharmacist’s Letter at [email protected].

BLS / CPR o All students must have a current and/or renewed certification, and students will

provide a copy of their current BLS/CPR (basic life support) or BCLS (basic cardiac life support) for adults, infant and child certification card.

o American Heart Association CPR BLS courses is the preferred provider for most rotation sites. Students may find courses offered through American/Canadian Heart Association or American/Canadian Red Cross websites. However, some rotation sites will require students to complete an American Heart Association CPR BLS course.

o Students do not need to take an ACLS course, only a BLS course. However, the

DDP Office will accept ACLS training certification.

o Students must be certified through live onsite training course specific for healthcare professionals. Most courses include AED training. Online/cognitive training courses are not accepted.

CU Student Orientation Information

o The Student Orientation Materials website page provides students with quick links to the available resources. Students will read through the information on this website page, and fill out the form that is located on the bottom of the website page.

Declaration Statement

o The declaration statement confirms your agreement to follow University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences and the Distance Degrees and Programs policies and procedures. You’ll sign and upload the attached Declaration Statement form into E*Value.

FERPA Form

o The FERPA form provides the Office of Experiential Programs, who coordinates the IPPE and APPE rotation site placement, and the DDP Office the permission to provide a copy of your immunization records, background check, and drug test to the rotation site. You’ll sign and upload the attached FERPA form into E*Value.

Professional Liability Insurance (Canadian Students Only)

o Canadian students must provide a copy of their Professional Liability Insurance rider if residing in Canada.

Cultural Competency Training – The cultural competency training discusses cultural

awareness, and the training is completed by both students and preceptors. This will be assigned to you after the add/drop date. You will complete as part of admissions and then prior to rotations. To access the training materials, follow these steps:

o Log into E*Value: https://www.e-value.net/login.cfm o Choose the SOP Program o Click on the “Evaluations” icon o Under the “Manage Evaluations”, click on “Complete Pending Evaluations” o Click on the Blue Highlighted “Edit evaluation” to open the training.

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Additional Immunization and Certification Requirements – Complete Prior to both IPPE and APPE Rotations

Intern License o Students completing rotations in Colorado – See instructions below within the

Immunization and Certification Requirements for Colorado Rotations section. Students should complete this 4-6 months prior to starting the rotation.

o Students completing rotations in states other than in Colorado – The state where you are completing your rotation may require you to have an intern license. You are responsible for checking and applying for an intern license, if needed. This should be completed 4-6 months prior to starting the rotation. Please refer to the NABP website learn about each state’s application process: http://www.nabp.net/boards-of-pharmacy/.

F-1 Visa

o A F-1 visa (educational visa) is required for students traveling from outside of United States to complete a rotation in any US-based rotation site. The University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences will sponsor the F-1 visa while completing a rotation at any US-based site. We will contact you well in advance of the rotation start date to begin processing the paperwork for the F-1 visa. An updated CV or resume is required to complete the paperwork.

Immunization Training (submit prior to APPE rotations only) o Rotation sites are requiring students to administer immunizations during their

rotation. Students will complete the immunization training prior to starting Advanced Pharmacy Practice Experiences (APPE). Instructions on how to complete this requirement are located in the Immunization Training policy.

Rotation Sites in the Alberta Canadian Province – Alberta SPA Agreement o Students planning a rotation in the Alberta Canadian province will complete the

Alberta SPA agreement paperwork, which relates to liability while on rotation. This paperwork needs to be signed by the University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences and the Alberta Health Services. Students will receive this paperwork during the rotation planning process.

Additional Site Requirements

o A rotation site may request additional requirements which must be submitted prior to the start of the rotation, and the DDP Office or the Office of Experiential Programs will notify you of any additional site requirements as provided by the rotation site.

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Additional Immunization and Certification Requirements for Colorado Rotations

Students who will complete either their IPPE and/or APPE rotations in Colorado will also complete these requirements. Unless otherwise noted below, these requirements are due by the deadline listed on page one of this document.

Intern License o Students who do not have a registered, Colorado RPh license must have a Colorado

intern license prior to starting any Colorado rotation(s). Students will need to apply for their intern license four to six months in advance of starting their rotation.

o Colorado intern licenses will expire on October 31, 2017. Students who received a Colorado intern license for a rotation completed earlier in the year will need to renew the Colorado intern license for any rotation that begins on or after November 1, 2017.

o Students with a social security number may apply online at: https://www.colorado.gov/pacific/dora/Pharmacy_Applications following the directions as listed on the DORA website. Students will send an email to the DDP Office after submitting the online application. Then, the DDP Office will send a separate letter to verify if the student is in good standing.

o Students without a social security number will need to submit the DORA Paper application along with the Social Security Number Affidavit which are attached below

Drug Test

o Students need to complete the Drug test the Wednesday prior to the start of their Colorado rotation.

o Review the attached drug test facilities form: Drug Test Facilities-CO Rotation. All of

the facilities listed on this form accept walk-in appointments. In order to complete the drug test, students will pick up the drug test form from the DDP Office at the University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences and bring the form to the drug test site.

o The cost of the drug test is $65 USD check or money order made payable to the University of Colorado Denver. The test must be paid for and the results from the drug test submitted to the DDP Office prior to the rotation start date.

Name Badge

o Students need to obtain their name badge the Wednesday prior to the start of their Colorado rotation.

o Students will need a special UC Denver photo ID for all Colorado rotations. We will

direct you to the coordinator via e-mail to have the badge made before the rotation starts. The authorization for the photo ID is only good for 30 days. Please bring Government ID when obtaining your name badge.

Name Tag

o The name tag is different from the name badge, and the Colorado State Board of Pharmacy require students wear a name tag on their lab coat.

o The name tag can be purchased at the Anschutz Medical Campus bookstore for

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around $10.30. Students should contact the Anschutz Medical Campus bookstore three weeks prior to the start of their rotation to make an appointment on the Wednesday before their rotation start date to obtain their name tag. Anschutz Medical Campus Bookstore: Phone: 303-724-2665 Hours: Monday – Friday 8:00am – 5:00pm MST

o The Colorado State Board of Pharmacy requires the information listed below on each

name tag: CU Logo Student’s First and Last Name The phrase “Intern Pharmacist” Student’s License Number

o The name tag should look like this:

CU Logo Student’s First and Last Name The phrase Intern Pharmacist here Intern license number OR pharmacy license number here

White Lab Coat o Students will need to wear a white lab coat while on rotation. The length of the lab

coat will be the short “student” style. Students may purchase a lab coat at the Anschutz Medical Campus Bookstore the Wednesday prior to starting the rotation.

Anschutz Medical Campus Bookstore: Phone: 303-724-2665 Hours: Monday – Friday 8:00am – 5:00pm MST

Attachments SOP Student Immunization Form Background Check Release Form Canadian Form Address Verification Form Declaration Statement FERPA Form DORA Paper application SSN Affidavit Form Drug Test Facilities – CO Rotation

The University of Colorado Denver Anschutz Medical Campus 2017-18 STUDENT IMMUNIZATION CERTIFICATION FORM

2017-18 Student Immunization Certification Form Revised 11/9/2016 Page 1 of 2

Student’s Name Last, First MI Telephone number Date of Birth Street address City, State, Zip

Degree/Program email address Please submit the completed form in E-Value: The following immunizations are required of all entering Anschutz Medical Campus Students. Please see the guidelines listed on the back of this form. Please list the dates, immunizations or titers were received for the following required immunizations. Should you have any questions, please email [email protected] or [email protected] .

MEASLES, MUMPS, RUBELLA (MMR): 1

Date of 1st Measles Vaccine: Date of 2nd Measles Vaccine: Date of Titer: Titer Result: Positive Negative Date of 1st Mumps Vaccine: Date of 2nd Mumps Vaccine: Date of Titer: Titer Result: Positive Negative Date of 1st Rubella Vaccine: Date of 2nd Rubella Vaccine: Date of Titer: Titer Result: Positive Negative HEPATITIS B: 2 Hep B: 1st) 2nd) 3rd) and/or Positive Hep B titer) Date: Titer Result: Titer Result: Positive Negative POLIO: list the dates of the four-shot childhood series.3 1) 2) 3) 4)

Date of polio booster ____________________ Date of Titer ______________________

TUBERCULIN SKIN TEST (within the past year) (Required Mantoux PPD): 4 Date of 1st PPD: Result Positive Negative

Date of 2nd PPD: Result: Positive Negative TB QuantiFERON Gold Result Positive Negative TB T-Spot: _____________________ Result Positive Negative

VARICELLA:5 Titer date: Result: Positive Negative If needed, Date of 1st vaccine: / / ___ Date of 2nd vaccine: / / ___ TDAP/TD: (circle one) TDAP or TD (must be within the last 10 years.) Date current TDAP/TD shot received: / / ___ INFLUENZA: Required Seasonal Immunization: (August – October 15) Date: / / ___

FOR INTERNATIONAL STUDENTS outside Canada and United States: three documented doses of TD are required. Primary vaccination of previously unvaccinated adults consists of three doses of adult tetanus-diphtheria toxoid (Td): 4-6 weeks should separate the first and second dose; the third dose should be administered 6-12 months after the second.

TO BE COMPLETED BY STUDENT - I understand that if my immunizations are not current, or in progress while in attendance at Anschutz Medical Campus, I may be subject to academic restrictions and may not be able to complete program/degree requirements. I authorize Anschutz Medical Campus to disclose this form and/or other information related to my immunization records to any clinical agency or other such entity in connection with my placement or participation in clinical internships, practica, affiliations and other programs related to my course of study.

Student Signature Required: ________________________________________________ Contact Number:

Date Signed:

TO BE COMPLETED BY CERTIFYING OFFICIAL Print Name (MD, DO, NP, PA, RN): Title:

Signature of person listed above:

Contact Number: Date Signed:

FOR ANSCHUTZ MEDICAL CAMPUS USE ONLY: Signature of Campus Official reviewing form:

Date Reviewed:

The University of Colorado Denver Anschutz Medical Campus 2017-18 STUDENT IMMUNIZATION CERTIFICATION FORM

2017-18 Student Immunization Certification Form Revised 11/9/2016 Page 2 of 2

IN THE EVENT OF AN OUTBREAK, EXEMPTED PERSONS WILL BE SUBJECT TO EXCLUSION FROM SCHOOL AND QUARANTINE Please be advised, by signing a waiver, students may be subject to academic restrictions regarding lab and/or clinical placement and may be unable to complete their program/degree requirements.

Medical Exemption: The physical condition of the above-named person is such that immunization would endanger life or health, or is medically contraindicated due to medical conditions. Physician’s Name (please print): Physician’s Signature: Date Signed: Contact Number: Email Address:

Personal Exemption: Parent or guardian of the above-named person or the person himself/herself is an adherent to a personal belief opposed to immunizations. Relationship and printed name of person signing this form: Date Signed: Signature of Person Signing this form: Contact Number:

1MEASLES, MUMPS, RUBELLA (MMR): The State of Colorado requires 2 MMRs. There must be documented evidence of shots or serologies. Measles, mumps and rubella require individual titers; there is no one titer for all three. List either the two dates of the MMRs received, or the individual titer dates and results. The first MMR must have been received on or after your first birthday, and there must be at least 28 days between the first and second MMR. If received prior to your first birthday or there is less than 28 days between the two MMRs received, you are required to have another MMR or show proof of positive titers. 2HEPATITIS B: If you are in the process of receiving your Hep B immunizations for the first time, you are required to have the three-shot series and provide the date and result of a positive titer 1-2 months after the third dose. If you are have completed your Hep B immunizations more then one year ago, please provide the date vaccines were received or the titer date and result. (Please note that although you may have previously had your Hep B immunizations and it may not be required as part of the admissions process to obtain a titer; however it may be requested later as some clinical sites now require proof of titers before students may begin rotations at their facilities). If the 3-dose series is needed, then the doses should be in a 0, 1, 6 month interval and then a titer done 1-2 months after the last dose. If immunity is not present, then another 3-dose series must be done followed by another titer. If after 6 doses no immunity is present, then the student is considered a “non-responder” and no further testing or immunization is required. 3POLIO: list the dates of the four-shot childhood series. For adults who had 1 or 2 IPV doses, and no documentation of childhood series, they will need to complete a total of three injections. Therefore, if they had one, they would need to receive an additional two adult catch-up injections; if they had 2, they would receive one additional adult catch-up injection.

International students are required to complete the 3 dose series or positive titer.

4TUBERCULIN SKIN TEST (Required Mantoux PPD): If you have never had a PPD or your current PPD is more than one year old, you are required to have the two-step method of testing done. The two-step requires placement of two separate PPD skin tests 7-14 days apart. All skin tests need to be read within 48-72 hours or another test is required. A single TB skin test administered after the initial exposure may elicit a negative response. The immune reaction wanes over time. Giving a second test stimulates the immune system to respond and may respond positively, indicating that the person was previously infected or exposed. It is important to differentiate between old and new infection. Please list the dates and a result for all PPDs received. After the initial two-step PPD, an annual PPD test is required.

If the PPD is positive (10mm and above), a negative chest x-ray is required, along with a copy of the physician’s report. A negative chest x-ray is valid for two years.

Instead of a PPD, it is acceptable to provide negative QuantiFERON gold blood test results. The QuantiFERON gold blood test will need to be completed annually.

International students who have received the Bacille Calmette‐Guerin Vaccine (BCG) will submit a physician’s report of a negative chest x‐ray, since the PPD will appear as a false positive. 5VARICELLA: Please list the date of the titer and result. A negative titer requires two vaccines placed one month apart. Or, if vaccines are required, list the dates they were received.

BACKGROUND DISCLOSURE AND AUTHORIZATION

In connection with my application for employment/training or continued employment/training with the University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences (SSPPS) or the “University”, and/or my application for admission or continued enrollment at the University, I understand that the University may request “consumer reports” and/or “investigative consumer reports” (collectively “Background Check Reports”) on me pursuant to the Fair Credit Reporting Act.

I understand that the Background Check Reports will be obtained by the University from HireRight, Inc. (“HireRight”), a consumer reporting agency that is located at 2100 Main Street, Suite 400, Irvine, CA 92614. HireRight can be contacted at 800-400-2761, option 3. Any such Background Check Reports may contain information bearing on my character, general reputation, personal characteristics, mode of living and credit standing. The types of information that may be obtained include but are not limited to: credit reports (for certain employment positions only), social security number verification, criminal records checks, public court records checks, driving records checks, educational records checks, verification of employment positions held, workers compensation records, personal and professional references checks, licensing and certification checks, etc. The information contained in these Background Reports may be obtained by HireRight from private and/or public record sources, including sources identified by me in my job and/or enrollment application or through interviews or correspondence with my past or present coworkers, neighbors, friends, associates, current or former employers, educational institutions or other acquaintances.

The nature and scope of any investigative consumer reports that may be requested is explained above. You are nonetheless entitled to request more information about the nature and scope of such reports by submitting a written request to the University at: University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences Office, 12850 E. Montview Blvd, Mail Stop C238, Suite 1116, Denver, Colorado, 80045.

Information about HireRight’ s privacy practices is available at www.hireright.com/Privacy-Policy.aspx.

I acknowledge that the University has with this form provided me a summary of my rights under the Fair Credit Reporting Act in a form issued by the Federal Trade Commission and entitled “Summary of Your Rights under the Fair Credit Reporting Act” located at http://www.ftc.gov/bcp/conline/pubs/credit/fcrasummary.pdf. If I am presently a resident of California, Maine, Minnesota, New York, Oklahoma, or Washington State, I have reviewed the additional state law disclosure information attached.

Costs associated with the required background check are the responsibility of the student and/or employee. Background checks are completed based upon residencies within the past seven years. Due to the variable nature of an individual student’s residencies, the resulting background check cost will vary. The Distance Degrees and Programs Office (DDP) Office will relay final background check costs to each student on an individual basis via email. Upon receipt, payment in full in U.S. dollars must be submitted directly to the DDP Office at 12850 E Montview Blvd, Mail Stop C238, Aurora CO 80045.

Please send this document to:

University of Colorado School of Pharmacy 12850 E. Montview Blvd, Mail Stop C238, Suite 1116, Denver, Colorado, 80045.

By my signature below, I expressly authorize and instruct HireRight to perform and release to the University a Background Check Report(s) on me at the request of the University in conjunction with my job and/or enrollment application. I understand that if the University hires and/or admits me, my consent will apply throughout my employment and/or enrollment to the extent permitted by law, unless I revoke or cancel my consent by sending a signed letter or statement to the University and to HireRight.

I understand that, to the extent allowed by law, information contained in my job and/or enrollment application or otherwise disclosed by me before, during or after my employment and/or enrollment, if any, may be utilized for the purpose of obtaining Background Check Reports.

I also understand that in the event I am applying for admission or continued admission to the university, (1) successfully completing the university’s background investigation is a prerequisite to clinical rotations at hospitals/other Affiliates, AND (2) Clinical rotations are a required component of my degree program and that if the results of this background Investigation render me unable to complete clinical rotations, the university may not permit me to enter/continue in its educational program.

By my signature below, I also authorize the disclosure to HireRight of information concerning my employment history, earning history, education, credit history, credit capacity and credit standing, motor vehicle history and standing, criminal history, and all other information HireRight deems pertinent by any individual, corporation or other private or public entity, including without limitation the following: employers; learning institutions; including colleges and universities; law enforcement agencies; federal, state and local courts; the military; credit bureaus; motor vehicle records agencies; and other applicable sources.

I further acknowledge that a telephone facsimile (FAX) or photographic copy of this release will be as valid as the original. I understand that any false statements or deliberate omissions on this document or any other document I file with University may be grounds for disqualification from employment/admission or, if discovered after I have been admitted or employment begins, could result in discipline up to and including my termination of employment/enrollment.

For residents of California, Maine, Minnesota, New York, Oklahoma, and Washington State only: You will be provided with a free copy of any consumer reports or investigative consumer reports on you if you check the box below. □ I wish to receive a free copy of any Background Check Report on me that is requested.

Last Name First _______Middle ___________ Program Name____________________________________________________________________________ Social Security # Date of Birth (for ID purposes only)

Present Address

City/State/Zip

Signature _________________________________________________Date_____________________________ Please respond to the following questions in the most complete and accurate manner possible. Do not identify convictions for which the criminal record has been expunged or sealed by the court. For purposes of the following questions, a “conviction” means guilty verdict, guilty plea or Nolo Contendere (“No Contest”) plea. Have you ever been convicted of a felony? No______ Yes______ If yes, please give details including date, state/county court in which conviction was entered, type of felony, etc. _______________________________________________________________________________________ Have you ever been convicted of a misdemeanor? No______ Yes______ If yes, please give details including date, state/county court in which conviction was entered, type of misdemeanor, etc.________________________________________________________________________________________ I have read the Background Investigation Consent and Release form and understand my rights.

ADDITIONAL STATE LAW NOTICES If you currently live in the state of California, New York, Oklahoma, Minnesota, Maine, or Washington State, please review these additional notices.

CALIFORNIA: Under  section  1786.22  of  the  California  Civil  Code,  you may  view  the  file maintained  on  you  by 

HireRight  during  normal  business  hours.    You  may  also  obtain  a  copy  of  this  file,  upon  submitting  proper 

identification and paying  the costs of duplication services, by appearing at HireRight’ s offices  in person, during 

normal  business  hours  and  on  reasonable  notice,  or  by mail.    You may  also  receive  a  summary  of  the  file  by 

telephone, upon submitting proper identification.  HireRight has trained personnel available to explain your file to 

you,  including any coded  information.    If you appear  in person, you may be accompanied by one other person, 

provided that person furnishes proper identification. 

NEW YORK, OKLAHOMA, and MINNESOTA: You have the right, upon request, to be informed of whether or not a consumer report was requested. If a consumer report is requested, you will be provided with the name and address of the consumer reporting agency furnishing the report. You may inspect and receive a copy of the report by contacting that agency. MAINE: You have the right, upon request, to be informed of whether an investigative consumer report was requested, and if one was requested, the name and address of the consumer reporting agency furnishing the report. You may request and receive from the Company, within five business days of our receipt of your request, the name, address and telephone number of the nearest unit designated to handle inquiries for the consumer reporting agency issuing an investigative consumer report concerning you. You also have the right, under Maine law, to request and promptly receive from all such agencies copies of any such reports. WASHINGTON STATE: If we request an investigative consumer report, you have the right, upon written request made within a reasonable period of time after your receipt of this disclosure, to receive from us a complete and accurate disclosure of the nature and scope of the investigation we requested. You also have the right to request from the consumer reporting written summary of your rights and remedies under the Washington Fair Credit Reporting Act. Rev. UCD SSPPS 8/2015  

Document Type International Release Form

Type de Document Formulaire d’Autorisation International

Your Name Votre nom

Canada – CPIC Compliant General Consent

Canada – CPIC- Consentement Général Conforme

If you have not already submitted this form to your employer, please complete the requirements in the table below and email all documents to [email protected] or fax it to (877) 797-3442 in the US and Canada or +1 (949) 224-6064 if outside of the US and Canada. If you have questions, please email [email protected]. If returning this form by email, please attach scanned images that are less than 15MB. Si vous n’avez pas déjà fait parvenir ce formulaire à votre employeur, prière de compléter les champs obligatoires dans le tableau ci-dessous et faire parvenir tous les documents à [email protected] ou par télécopieur au (877) 797-3442 aux États-Unis et du Canada ou au +1 (949) 224-6064 à l’extérieur des États-Unis et du Canada. Pour toute question, prière d’envoyer un courriel à [email protected]. Si vous retourner ce formulaire par courriel, veuillez attacher des images numériques de moins de 15MB au total.

Below are the requirements set forth by the CPIC (Canadian Police Information Centre) to request a Criminal Records Check. Please make sure that all information and documents listed in this checklist are included and legible before submitting. All incomplete and illegible requests will be returned.

Vous trouverez ci-dessous les exigences stipulées par le Centre d’Information de la Police Canadienne (IPC) pour faire une demande de recherche et divulgation du casier judiciaire. Veuillez vous assurer que toute l’information et les documents apparaissant sur la liste ci-dessous sont inclus et lisibles avant de soumettre la demande. Toute demande incomplète ou illisible sera retournée.

Completed Cover Sheet

Include Applicant Name

Page Couverture Incluant le nom du candidat

Completed CPIC Form

All sections of the form must be completed. The “Identity Verification for CPIC Search/es” section of the CPIC Form must be signed by either an authorized

representative of the employer (the organization requesting the background report) or a notary public.

Formulaire de l’IPC complété

Toutes les sections du formulaire doivent être complétées La section “Vérification De L'identité Pour Recherche(S) CPIC” du formulaire de l’IPC doit être signé soit par un

représentant autorisé de l’employeur (l’organisation qui fait la demande de vérification de casier judiciaire) ou par un notaire public.

Copies of 2 forms of ID

1.Acceptable Identification: (Must be valid and not expired) Driver’s License (issued by Canadian Province or Territory)

Foreign Driver’s License

Canadian Passport

Foreign Passport

Canadian Citizenship Card

Permanent Resident (PR) Card

Certificate of Indian Status

Firearms Acquisition Certificate (FAC)

Canadian National Institute of the Blind (CNIB) Identification Card

Federal, provincial, or municipal employee identification card

Military Family Identification Card (MFID)

Provincial ID Card

International Student Identity Card

2.Acceptable as a second piece of ID, in support of the above piece: Photo healthcare card (Ontario & Quebec ONLY)

Birth Certificate

Baptismal Certificate

Hunting/Fishing/Boating Licence

LCBO Card

Hospital Card / Blood Donor Card

Immigration Papers

Student Identity Card (Canadian & International)

Addressed mail from Revenue Canada indicating the subject’s name, date of birth, and current address (Note Black out Social Insurance

Number prior to forwarding) Other ID cards issued by Provincial Ministries

Copy of an recent pay stub / Copy of an Income Tax stub

Provincial Health Cards

The information, photos and signatures on both ID’s must be viewed and verified in- person by either an authorized representative of the employer or notary public. (Please see the identification section of the CPIC form.)

Copies de 2

pièces d’identités

1. Pièces d’identité acceptables: (Doit être valide et non expiré) Permis de conduire (émis par une province ou un territoire canadien) Permis de conduire étranger Passeport canadien Passeport étranger Carte de citoyenneté canadienne Carte de résidence permanente (RP) Certificat du statut d’Indien Autorisation d’acquisition d’armes à feu (AAAF) Carte d’identité de l’Institut national canadien pour les aveugles (INCA) Carte d’identité d’employé fédéral, provincial ou municipal Carte d’identité de famille militaire (CIFM) Carte d’identité d’employé fédéral, provincial ou municipal Carte d’étudiant international

2. Acceptable en tant que seconde pièce d’identité, accompagné d’une des pièces ci-dessus :

Carte d'assurance maladie avec Photo (Ontario et Québec seulement)

Certificat de naissance

Certificat de Baptême/pêche/navigation

Carte du LCBO

Carte d’Hôpital/Carte de donneur de sang

Documents d’immigration

Carte d’étudiant (Canadienne et Internationale)

Envoi postal provenant de Revenu Canada indiquant le nom de l’individu, la date de naissance et l'adresse actuelle (REMARQUE : Prière de cacher ou noircir le numéro d’assurance sociale avant de le transmettre)

Autres cartes d’identité émises par les ministères provinciaux

Copie d’un relevé de paye récent/Copie d’un relevé fiscal

Carte d’Assurance Maladie émises par une province ou un territoire canadien

L’information, photos et signatures contenues sur les deux pièces d’identité doivent être vues et vérifiées en personne par un représentant autorisé de l’employeur ou un notaire public. (Voir la section identification du formulaire CPIC).

INFORMED CONSENT FORM (CANADA) Criminal History Searches

CONSENTEMENT ÉCLAIRÉ (CANADA) Recherche d’Antécédents Criminels

HireRight Canada - Informed Consent – Criminal Record Searches – Rev 04/2014

HireRight Canada - Consentement éclairé - Recherche d’Antécédents Criminels – Rev 04/2014

Page 1 of 2

PLEASE PRINT (to be completed by applicant)

EN LETTRES D’IMPRIMERIE (à remplir par le candidat) Surname (Provide previous name/s if applicable): Nom de famille (Indiquez le ou les noms utilisés avant la candidature le cas échéant):

First Name: Prénom:

Second Name: Deuxième nom:

Maiden Name or Other Surnames Used (if applicable): Nom de jeune fille ou autres noms utilisés (le cas échéant):

Place of Birth (If other than Canada note date of entry to Canada): Lieu de naissance (si hors du Canada, veuillez aussi noter la date d’entrée au Canada):

Date of Birth: Date de naissance: (YY-MM-DD) (AA-MM-JJ)

Sex: Sexe:

Current Address/Adresse actuelle: Number/Numéro: Street/Rue:

Apt/Unit: App./Unité:

City/Province/Country: Ville/Province/Pays:

Postal Code: Code Postal:

Dates:

Note: provide previous addresses (last Canadian address) if you did not reside at the above address for more than five years Remarque : fournissez les adresses précédentes (dernières adresses Canadiennes) si vous ne résidez pas à l’adresse ci-dessus depuis plus de cinq ans

Number/Numéro: Street/Rue:

Apt/Unit: App./Unité:

City/Province/Country: Ville/Province/Pays:

Postal Code: Code Postal:

Dates:

Number/Numéro: Street/Rue:

Apt/Unit: App./Unité:

City/Province/Country: Ville/Province/Pays:

Postal Code: Code Postal:

Dates:

AUTHORIZATION FOR REQUESTED SEARCH(ES) (Notary Or Representative Of Employer / Organization To Complete) AUTORISATION POUR LA/LES RECHERCHE(S) DEMANDÉE(S) (À Remplir Par Le Notaire Ou Représentant De L'employeur / Entreprise)

Acceptable: Driver’s Licence, Birth Certificate, Passport, Permanent Residency Card Acceptable : permis de conduire, acte de naissance, passeport, carte de résident permanent

NOT Acceptable: SIN Card, Invalid / Expired ID

NON Acceptable : carte d'assurance sociale, pièce d'identité non valable ou expirée

IDENTIFICATION TYPE TYPE D'IDENTIFICATION

ID NUMBER Nº D'IDENTIFICATION

IDENTIFICATION TYPE TYPE D'IDENTIFICATION

ID NUMBER Nº D'IDENTIFICATION

1. 2.

WITNESSING APPLICANT’S IDENTIFICATION/ TÉMOIN POUR L'IDENTIFICATION DU CANDIDAT

I verify that I have witnessed two pieces of the Applicant’s Identification, one of which is government issued with a photograph and the Applicant’s signature, and attached a copy of each in a legible format. J'atteste avoir vérifié deux pièces d'identité du candidat, dont une est délivrée par un gouvernement, sur lesquelles se trouve une photo et la signature du candidat, et joint une copie de chacune dans un format lisible.

Notary or Employer / Organization Name: Nom du Notaire ou Employeur / Organisation:

Witness Name: Witness Signature:

Nom du témoin: Signature du témoin:

* Witness must be either (i) a Notary, or (ii) a representative of the Company engaging HireRight to conduct the Criminal Record Check on its behalf. The Witness must verify the Applicant’s identity by comparing the signature on the Applicant’s government issued photo identification to the Applicant’s signature below. The Witness’s signature above confirms that the Witness has verified the identity of the Applicant by means of two (2) pieces of government identification and has verified that the signature of the Applicant’s photo identification matches the Applicant’s signature on this Consent Form.

* Le témoin doit être soit (i) un Notaire ou, (ii) un représentant de l’Entreprise désignant HireRight pour effectuer la vérification du Casier Judiciaire en son nom. Le témoin doit vérifier l’identité du candidat en comparant la signature se trouvant sur la pièce d’identité avec photo et délivrée par un gouvernement à la signature du candidat ci-dessous. La signature du témoin ci-dessus confirme que le témoin a vérifié l’identité du candidat au moyen de deux (2) pièces d’identité délivrées par un gouvernement et que la signature du candidat sur la pièce avec photo correspond à la signature du candidat sur ce formulaire de consentement.

INFORMED CONSENT FORM (CANADA) Criminal History Searches

CONSENTEMENT ÉCLAIRÉ (CANADA) Recherche d’Antécédents Criminels

HireRight Canada - Informed Consent – Criminal Record Searches – Rev 04/2014

HireRight Canada - Consentement éclairé - Recherche d’Antécédents Criminels – Rev 04/2014

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AUTHORIZATION AND WAIVER TO RELEASE CRIMINAL RECORD AND CRIMINAL/POLICE INFORMATION I am aware and give consent to the release of a Criminal Record or any Criminal/Police Information by the processing Police Service to Canadian Employment Screening to disseminate and transmit the results electronically (or in hard copy) to HireRight, for further dissemination and transmission to the employer/prospective employer designated below. I hereby release and forever discharge all members and employees of the processing Police Service from any and all actions, claims and demands for damages, loss or injury howsoever which may hereafter be sustained by myself, as a result of the disclosure of information by the processing Police Service to Canadian Employment Screening and HireRight.

AUTORISATION DE DIVULGATION DU CASIER JUDICIAIRE ET AUTRE INFORMATION POLICIERE ET QUITTANCE En connaissance de cause, je consens à la divulgation d'un casier judiciaire ou de tout renseignement d'ordre criminel ou policière par les services de police traitant la demande à Canadian Employment Screening aux fins de diffusion et transmission électronique (ou sur papier) des résultats à HireRight, pour des fins de diffusion et transmission subséquente à mon employeur/ employeur potentiel.

Par la présente, je tiens indemne et libère à jamais tous membres et employés des services de police ayant effectués la vérification, relativement à toute actions, réclamations ou demande d’indemnité pour tous dommages, pertes, dommages corporels à ma personne, occasionnés par la divulgation d’information par les services de police à Canadian Employment Screening et HireRight.

REASON FOR THE CONSENT/ RAISON DU CONSENTEMENT

Description of Position Name of Employer / Organization Requiring the Criminal Record Verification [“COMPANY”] Description du poste Nom de l'employeur/ Organisation demandant la recherche du casier judiciaire [“COMPAGNIE”]

SEARCH AUTHORIZATION AND DECLARATION

By signing this form, I certify that the information set out by me in this application is true and correct to the best of my ability.

I understand that a search of the RCMP National Repository of Criminal Records and CPIC Investigative Data Bank will be conducted based on the name(s) and date of birth I have provided above.

By my signature below, I authorize the processing Police Service to conduct a name-based criminal record verification on me and to disclose criminal record information pertaining to me to COMPANY through Canadian Employment Screening and HireRight, which are obtaining information about me on behalf of COMPANY. I consent to the storage or dissemination of such information to or at a location outside of Canada by or to Canadian Employment Screening, HireRight and COMPANY. I understand that the information is collected and disclosed according to applicable Canadian privacy laws, including but not limited to the Federal Privacy Act, MFIPPA, PIPA, PIPEDA and Quebec Privacy Laws, each to the extent applicable. It may also be subjected to applicable International laws, i.e. U.S. Patriot Act.

AUTORISATION DE RECHERCHE ET DÉCLARATION

En signant ce formulaire, j'atteste que l’information que j’ai fournie dans ce formulaire est exacte et véridique au meilleur de mes connaissances.

Je comprends qu'une recherche auprès du Dépôt National des Casiers Judiciaires tenue par la GRC et de la Banque de Données d’Enquête CIPC sera effectuée d’après le(s) nom(s) et date de naissance que j'ai fournie ci-dessus.

Par ma signature ci-dessous, j’autorise les Service de Police traitant la demande à effectuer une vérification nominale de mon potentiel casier judiciaire et à divulguer ces informations relatives au Casier Judiciaire me concernant à COMPAGNIE par l’intermédiaire de Canadian Employment Screening et HireRight, lesquels obtiennent de l’information me concernant de la part de COMPAGNIE. Je consens à l’enregistrement ou diffusion de cette information aux bureaux situés hors du Canada par ou à Canadian Employment Screening, HireRight et COMPAGNIE.

Je comprends que les renseignements sont recueillis et divulgués conformément à la Loi sur la protection des renseignements personnels applicable, incluant mais non limitée à LAIMPVP, la LPRPDE et les lois québécoises relatives à la protection des renseignements personnels, chacune dans la mesure applicable. Ils peuvent également être assujettis aux lois internationales applicables, par exemple la Patriot Act aux États-Unis.

Date Signature of Applicant / Signature du candidat

Address Verification Form  

University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences

Distance Degrees and Programs International-Trained PharmD and North American-Trained PharmD

Programs   In addition to the Background Check Release Form, Hire Right, the university’s provider of background 

check services will require a list of home addresses from the past seven years.  Please list all places 

where you have lived over the past seven years beginning with your current address. 

Name: Email Address:   Passport Number: __________________________Country of Passport:________________  Current Address Street Address: Building/House # _________ City: State:_ _Mail Code: Country: From Date: To Date:

Previous Address(es)– using the above format, please list all addresses over the past seven years. Please use additional pages if necessary. 

Last Updated: June 20, 2014

Distance Degrees and Programs Office

North American-Trained PharmD Program

Pharmacy & Pharmaceutical Sciences Bldg.

12850 E. Montview Blvd., Room V20-1116

Aurora, CO 80045

Mail Stop (C238-V20)

303-724-3582 office

303-724-3732 fax

[email protected]

[email protected]

www.ucdenver.edu/pharmacy

Declaration Statement

Declaration

I understand there are policies and procedures designed to assist and provide guidance to students

completing within the North American-Trained PharmD (NTPD) Program and the International-

Trained PharmD (ITPD) didactic and experiential training requirements. These policies and

procedures are intended to optimize the learning experience and ensure the on-going success of

both Programs. I have reviewed a copy of these policies and procedures located on the following

website pages:

1.) Policies and Procedures – This page defines program and the University of Colorado Skaggs

School of Pharmacy and Pharmaceutical Sciences specific policies and procedures,

including the Student Bulletin, Student Advancement and Appeals policy, and Student Ethics

and Conduct Code.

2.) Experiential Training – This page links to specific policies and procedures pertaining to the

experiential training requirements for both programs.

As a student of the University of Colorado Skaggs School of Pharmacy and Pharmaceutical

Sciences, I will abide by the policies and procedures pertaining to the Distance Degrees and

Programs and the School. I understand the Distance Degrees and Programs Office and the School

reserves the right to modify the policies and procedures at any time.

Students and preceptors will be notified of any changes in the documents. Questions about the

policies and procedures will be directed to the Academic and Experiential Program Coordinator.

Your signature below indicates you have received, read and understand the Distance Degrees and

Programs’ policies and procedures.

_________________________ _________________________

Student Signature Printed Name

_________________________ _________________________

Date Student ID Number

Distance Degrees and Programs Office

Pharmacy & Pharmaceutical Sciences Bldg.

12850 E. Montview Blvd., Room V20-1116

Aurora, CO 80045

Mail Stop (C238-V20)

303-724-3582 office

303-724-3732 fax

[email protected]

[email protected]

www.ucdenver.edu/pharmacy

I understand that at the post-secondary level, pursuant to the Family Educational Rights and Privacy Act of 1974 (FERPA) and University policy, no individual person possesses the inherent right to inspect my education records, including my immunization records, background check and drug test results. However, education records may be released with my written consent. By signing this form, I,______________________ give my permission for the Distance Degrees and Programs Office and Office of Experiential Programs at the University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences to provide a copy of my immunization records, background check, and drug test to the hospital or community pharmacy sites at which I will receive clinical training if necessary to comply with the requirements of the hospital or community pharmacy site. I understand that this permission will allow the Distance Degrees and Programs Office and Office of Experiential Programs to release this information to the specified parties until I revoke this permission or am no longer enrolled in a program at the University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences.

_____________________________ _____________________________ Signature Date

Division of Professions and Occupations Office of Licensing—Pharmacy 1560 Broadway, Suite 1350 Denver, CO 80202 (303) 894-7800 / Fax (303) 894-7693 www.dora.colorado.gov/professions

Application PHARMACY INTERN (IN)

Fee:$80 Fees may be paid by a check or money order drawn in U.S. dollars

on a U.S. bank and made payable to State of Colorado.

Applicant: Keep this page for your records. 07/2015

APPLICANT INSTRUCTIONS

Basic Requirements. Requirements for licensure are outlined in the Section 12-42.5-101(17) of the Colorado Revised Statues (C.R.S.) and the Board Rules, specifically Rule 4.00. Both are available online at: www.dora.colorado.gov/professions/pharmacy.

About the Application. This application is to be completed by you and returned to the Office of Licensing. All questions on the application are mandatory, and all supporting documents must be submitted with the application. You may copy as many forms as needed; however, each form submitted must be completed in original ink or typed. Keep a copy of the completed application for your records.

Social Security Number is Required. Effective January 1, 2009, a Social Security Number is required for all licensees. The Division will consider an application to be incomplete when the applicant fails to submit their Social Security Number. Exceptions are made for foreign nationals not physically present in the United States and for non-immigrants in the United States on student visas who do not have a Social Security Number. These applicants must submit a signed Social Security Number Affidavit in lieu of a Social Security Number.

Application Expiration. Your application will be kept on file for one (1) year from date of receipt in the Division. Your file and all supporting documentation will be purged if you do not submit required documents and complete your application process in one year. You will need to resubmit a new application packet and fee after that time.

Disclosure of Addresses. Consistent with Colorado law, all addresses and phone numbers on record with the Division are public record and must be provided to the public when requested. It is your responsibility to keep your contact information current in our system. Your email address is not open to public record, but must be provided in this application. Any requests for additional information, license information and renewal notices will be emailed to the email address on record. If your email address is not current, it is possible you will not receive important information from the Division. You can change your contact information online by using Online Services at: www.dora.colorado.gov/professions/onlineservices.

Checking Your Application Status. Visit Online Services at: www.dora.colorado.gov/professions/onlineservices to track your application from the date we log it in our database to the date your license is available for printing. Please allow us enough time to receive the application through the mail and enter your application into our database before you check the website. We recommend waiting at least 10 business days from date of mailing before checking the status of your application.

License Expiration Grace Period for New Applicants. All new applicants who are issued a license within 120 days of the upcoming renewal expiration date will be issued a license with the subsequent expiration date. For example, licenses issued between July 4, 2015 and October 31, 2015 will reflect an expiration date of October 31, 2017. Licenses issued prior to July 4, 2015 will reflect an expiration date of October 31, 2015, and must renew in the upcoming renewal period.

All Pharmacy Intern licenses expire on October 31 of odd-numbered years and must be renewed to continue practicing.

Printing your License upon Approval. DORA is no longer printing and mailing wallet cards as licenses. To print your wallet card license in its current status, login to your Online Services account at: www.dora.colorado.gov/professions/onlineservices and select “Print Your License” in the left-hand menu.

If you are licensed as a pharmacist in another state and are not enrolled in the non-traditional pharmacy program at the University of Colorado, you are NOT eligible to be an intern.

Do NOT start practicing as an intern until a license number is assigned to you.

Do NOT work in a pharmacy without the presence of a licensed Pharmacist.

Be sure your Preceptor is approved as such by the Board of Pharmacy.

An Intern Hours Affidavit form is available online at: www.dora.colorado.gov/professions/pharmacy. Intern Hours Affidavit form must be submitted to obtain credit for intern hours upon applying for licensure as a pharmacist.

Division of Professions and Occupations Office of Licensing—Pharmacy 1560 Broadway, Suite 1350 Denver, CO 80202 (303) 894-7800 / Fax (303) 894-7693 www.dora.colorado.gov/professions

Application PHARMACY INTERN (IN)

Fee:$80 Fees may be paid by a check or money order drawn in U.S. dollars

on a U.S. bank and made payable to State of Colorado.

Applicant: Keep this page for your records. 07/2015

APPLICANT CHECKLIST

To apply for a Colorado Pharmacy Intern license:

Complete the attached application. Return the completed application and all supporting documentation to the Office of Licensing.

Enclose the non-refundable application processing fee. Fees may be paid by a check or money order drawn in U.S. dollars on a U.S. bank and made payable to State of Colorado. All fees are non-refundable and subject to change every July 1.

Provide documentation of any name change. If your name has changed since you obtained a previously-issued license, or if your name is different on any of your supporting documentation, you must provide a copy of the legal document verifying the name change (i.e., marriage license, divorce decree, or court order).

Provide proof of enrollment with an approved school or pharmacy in the form of ONE of the following:

A Dean’s letter certifying attendance and status as a student or graduate; —OR—

An official transcript showing the degree conferred and date.

Foreign-trained Graduates should include a certified copy of their Foreign Pharmacy Graduate Examination Committee (FPGEC) certificate. Contact the National Association of Board of Pharmacy Foundation, Foreign Pharmacy Graduate Examination Committee online at: www.nabp.net or telephone (847) 391-4406.

Complete and maintain an online Healthcare Professions Profile. Once your application is received and entered into the Division of Professions and Occupations database, you must create and maintain a Healthcare Professions Profile on our website at: www.dora.colorado.gov/professions/hppp. You may begin checking the Healthcare Professions Profiling Program (HPPP) website within a few days of submitting your application. If you cannot create your profile within 14 days of submitting your application, or if you have questions or technical issues regarding your online profile, contact the HPPP at (303) 894-5942. Your application is not considered complete, and a license will not be issued until you have submitted the online profile. Your Healthcare Professions Profile is an ongoing responsibility; a profile must be updated online within 30 days of changes and/or reportable events.

Incomplete applications may delay processing time.

Return your completed application packet and all supporting documentation to:

Division of Professions and Occupations Office of Licensing—Pharmacy

1560 Broadway, Suite 1350 Denver, CO 80202

1560 Broadway, Suite 1350, Denver, CO 80202 P 303.894.7800 F 303.894.7693 www.dora.colorado.gov/professions

I M P O R T A N T N O T I C E

TO: All Applicants

FROM: Director of the Division of Professions and Occupations

SUBJECT: Licensure and Criminal History

Thank you for your interest in becoming a licensed* professional within the Division of Professions and Occupations. Before you submit your application, please be aware of a few facts regarding criminal conduct, convictions, and disciplinary actions in other states.

The mission of the Division of Professions and Occupations is “public protection through effective licensure and enforcement.” One way the Division safeguards consumers is by issuing licenses to fully qualified, competent, and ethical applicants.

During the licensing process – and depending on the specific application – the Division may ask whether you have ever been disciplined in any state, arrested, charged, convicted, or pled guilty to a crime. An arrest, subsequent criminal conviction, or disciplinary action is not an automatic disqualification from licensure. Rather, the appropriate board or program will look at the facts surrounding the criminal conduct and disciplinary action in addressing your license application. You should know that licensure is a privilege, not a right. One thing you must do to obtain the privilege is to be complete and accurate in disclosing information on your application.

Be sure to list all relevant complaints, disciplinary actions, arrests, charges, or convictions in response to the appropriate licensure questions. Failure to fully and accurately disclose requested criminal history information, alone, could constitute grounds for denial of your application or revocation of your license. When requested, you must include information regarding prior conduct. This remains the case when the conduct is seemingly unrelated to the activities of a profession, and when the conduct involves deferred sentences or judgments.

Remember, even following licensure, you are still required to notify your professional licensing board or program about subsequent convictions and disciplinary actions in other states.

Please be aware that the Division conducts audits of its licensing database against several criminal and national disciplinary databases. This allows the Division to verify the truthfulness of your application and track subsequent criminal and disciplinary conduct after initial licensure. Keep in mind, your license will not necessarily be revoked, or your application denied, if you have been disciplined, arrested, charged or convicted. But, you will most likely be denied or revoked if you fail to disclose requested information.

*The word "license" is used as a general term. While most of the professions and occupations are licensed, others may be registered, certified, or listed. For precise terminology and requirements related to a profession or occupation, please consult the website of the appropriate board or program.

Division of Professions and Occupations Office of Licensing—Pharmacy 1560 Broadway, Suite 1350 Denver, CO 80202 (303) 894-7800 / Fax (303) 894-7693 www.dora.colorado.gov/professions

Application PHARMACY INTERN (IN)

Fee:$80 Fees may be paid by a check or money order drawn in U.S. dollars

on a U.S. bank and made payable to State of Colorado.

* Social Security Number Disclosure. Section 24-34-107(1) of the Colorado Revised Statutes requires that every application by an individual for a license issued pursuant to the authority set forth in title 12, C.R.S., by the Department of Regulatory Agencies, shall require the applicant's social security number. Disclosure of your social security number is mandatory for purposes of establishing, modifying, or enforcing child support under § 14-14-113 and § 26-13-126, C.R.S.; locating an individual who is under an obligation to pay child support as required by § 26-13-107(3)(a)(I)(A), C.R.S.; and reporting to the Health Integrity and Protection Data Bank as required by 45 CFR §§ 61.1 et seq. Failure to provide your social security number for these mandatory purposes will result in the denial of your licensure application. Disclosure of your social security number is voluntary for disclosure to other state regulatory agencies, testing and examination vendors, law enforcement agencies, and other private federations and associations involved in professional regulation for identification purposes only. Your social security number will not be released for any other purpose not provided for by law.

OFFICE USE ONLY LICENSE NUMBER: ____________________________ DATE ISSUED: _________________________________

Pharmacy Intern Page 1 of 3 07/2015

The content of this application must not be changed. If the content is changed, the applicant may be referred to the Colorado State Attorney General’s Office for violation of Colorado law.

PART 1—APPLICANT INFORMATION

Name: First:

Middle: Last: Suffix:

Previous Name(s):

Social Security Number: *

E-mail Address:

(This will be the primary communication method) Mailing Address:

This is a Home Business

PO Box, Street:

City, State, Zip:

Daytime Telephone Number: ( ) Date of Birth (mm/dd/yyyy):

Place of Birth (city and state, or foreign country): Gender: Male Female

PART 2—EDUCATION AND EXPERIENCE

Pharmacy school attending: Original date of enrollment:

Are you enrolled in the non-traditional pharmacy program at the University of Colorado? YES NO

► If YES, have state(s) where you are licensed as a pharmacist send verification of licensure and good standing.

Are you a licensed intern in another state, territory, or country? YES NO

► If YES, list details (if needed, attach an additional sheet using the same format):

State License Number Issue Date

Are you a licensed pharmacist in another state, territory, or country? YES NO

► If YES, list details (if needed, attach an additional sheet using the same format):

State License Number Issue Date

APPLICANT NAME: __________________________________________

Pharmacy Intern Page 2 of 3 07/2015

PART 2—EDUCATION AND EXPERIENCE (Continued)

Do you hold a Foreign Pharmacy Graduate Examination Committee (FPGEC) Certificate? YES NO

► If YES, give EE number and effective date:

Name of last Pharmacy school attended: Date last attended:

Name of Dean: Reason for non-attendance: (i.e., graduation)

PART 3—MILITARY QUESTIONS

1. Are you a Member of the U.S. military? YES NO

If YES, provide information below:

Branch: Duty Station:

2. Are you the spouse of an active duty military member who has been relocated to Colorado and hold a currently valid and active credential to practice your profession in another state?

YES NO If YES, refer to the Military Spouse Exemption Form available on our website

at:www.dora.colorado.gov/professions/military.

PART 4—SCREENING QUESTIONS

If your answer is YES to any of the following questions, provide additional details or an explanation on a separate sheet and copies of all available court documents. *

1. Have you ever been convicted of, pled guilty to, pled nolo contendere to, or received a deferred judgment for a felony? YES NO

2. Have you ever been convicted of, pled guilty to, pled nolo contendere to, or received a deferred judgment for a violation involving alcohol or controlled substances (including but not limited to DUI or DWAI)?

YES NO

3. Have you ever been convicted of, pled guilty to, pled nolo contendere to, or received a deferred judgment for any offense pertaining to state or federal drug law? YES NO

4. Have you ever had any disciplinary action taken against your license or pending against you in any state? YES NO

5. In the last five years, have you been diagnosed with or treated for a condition that significantly disturbs your cognition, behavior, or motor function, and that may impair your ability to practice as a pharmacy intern safely and competently including but not limited to bipolar disorder, severe major depression, schizophrenia or other major psychotic disorder, a neurological illness, or sleep disorder?

YES NO

6. Do you have, or have you had, any malpractice judgments rendered against you? YES NO

7. Do you now abuse or excessively use, or have you in the last five years abused or excessively used, any habit forming drug, including alcohol, or any controlled substance that has a) resulted in any accusation or discipline for misconduct, unreliability, neglect of work, or failure to meet professional responsibilities; or b) affected your ability to practice as a pharmacy intern safely and competently?

YES NO

APPLICANT NAME: __________________________________________

Pharmacy Intern Page 3 of 3 07/2015

* Please be advised an affirmative response to one of the screening questions may delay your application. For affirmative responses for any reason, provide a detailed explanation.

• If an affirmative response is due to any type of court action, provide copies of all court documents, including the charges, plea agreement or jury verdict, sentencing, and documentation that you completed all court ordered requirements. Failure to provide this information may result in your application being delayed.

• If an affirmative response is due to a disciplinary action from another state board of pharmacy, provide a copy of the disciplinary action, a detailed explanation of the circumstances surrounding the action, and, if applicable, documentation that you have completed all requirements ordered by the action. Failure to provide this information may result in your application being delayed.

In addition, if you have had any of the following:

• two or more alcohol related infractions within the five years preceding the application, • three or more alcohol related infractions within the ten years preceding the application, or • any substance abuse and related issues in the five years preceding your application which may impair your ability to practice pharmacy,

The Board may direct you to be assessed by the Pharmacy Peer Health Assistance Program (PPHADP) prior to acting on your application. Therefore, the Board is providing advance notice of this possibility so that applicants may contact PPHADP to schedule an evaluation at the beginning of the application process. By doing so, the application should not be unduly delayed. An applicant is not required to contact PPHADP in advance of Board consideration of the application. The applicant may choose to wait for a specific decision by the Board that a PPHADP evaluation is necessary. However, doing so will delay a final decision regarding your application. Contact information for the Pharmacy Peer Health Assistance Program is as follows: Pharmacy Peer Health Assistance Diversion Program (PPHADP), 2170 South Parker Road, Suite 229, Denver, CO 80231; (303) 369-0039 or (866) 369-0039. ATTESTATION

I state under penalty of perjury in the second degree, as defined in §18-8-503, C.R.S., that the information contained in this application is true and correct to the best of my knowledge. In accordance with § 18-8-501(2)(a)(I), C.R.S., false statements made herein are punishable by law and may constitute violation of the practice act. I must comply with federal and state laws, rules and regulations of the State Board of Pharmacy, and must submit such reports as requested by the State Board of Pharmacy. I am aware that I may not legally compound or dispense drugs or medicines except under the immediate and personal supervision of a registered pharmacist. Applicant Signature Date

Social Security Number Affidavit 08/2012

Colorado Department of Regulatory Agencies Division of Professions and Occupations

1560 Broadway, Suite 1350 Denver, CO 80202

Phone: (303) 894-7800

SOCIAL SECURITY NUMBER AFFIDAVIT

LICENSEE/APPLICANT INFORMATION

Name: Last: First: Middle: Suffix:

Date of Birth (mm/dd/yyyy): Daytime Telephone Number: ( )

Physical Address:

PO Box or Street, City: State or Foreign Country, Zip or Postal Code:

Mailing Address: (if different than Physical Address)

PO Box or Street, City: State or Foreign Country, Zip or Postal Code:

Profession or Occupation: License, Certification, or Registration Number: (leave blank if this is a new application)

1. I am applying for or renewing a professional or occupational license, certification, or registration in the

State of Colorado for the profession or occupation identified above.

2. I do not have a social security number and (check one of the following):

I am not physically present in the United States.

I am a non-immigrant in the United States on a student visa.

I am a non-immigrant P-1 individual athlete in the United States on an authorized stay pursuant to Title 8, Section 214.2(p) of the Code of Federal Regulations and Section 214(a)(2)(B) of the Federal Immigration and Nationality Act.

3. I am the person identified above and the information contained herein is true and correct to the best of my

knowledge. I understand that under Colorado law, providing false information is grounds for denial, suspension, or revocation of a license, certification, registration, or permit.

ATTESTATION

I state under penalty of perjury in the second degree, as defined in C.R.S. 18-8-503, that the information contained in this application is true and correct to the best of my knowledge. In accordance with C.R.S. 18-8-501(2)(a)(l), false statements made herein are punishable by law and may constitute a violation of the practice act. Signature Date

Name Address City State Zip Phone Hours DA Walkin Non- Electronic San Luis Valley Reg Med Occup Hlth 2115 Stuart Ave Alamosa CO 81101 719-589-8110 Mon-Fri 8:00AM-10:00AM

Mon-Fri 1:00PM-3:00PMYes X No

Concentra Medical Center 10355 East Iliff Avenue Aurora CO 80247 303-755-4955 Mon-Fri 8:00AM-5:00PM Yes X NoConcentra Medical Center 15235 E 38th Ave Aurora CO 80111 303-340-3053 Mon-Fri 8:00AM-8:00PM Yes X NoQuest Diagnostics-Aurora South 1411 S. Potomac Street, Suite 290 Aurora CO 80012 303-283-0838 Mon-Fri 10:00AM-3:30PM Yes X Yes

Wiz Quiz 1701 Chambers Aurora CO 80011 303 537-5057 Mon-Fri 9am-3pm and 6:15-8:15 pmWiz Quiz 2260 S Xanadu Way Suite 270 Aurora CO 80014 Verify hours prior to test. Mon-Fri

9:00AM-5:00PMSat 10:00AM-12:00PM

Yes X Yes

Concentra Medical Center 3300 28th St Boulder CO 80301 303-541-9090 Mon-Fri 8:00AM-8:00PMSat 10:00AM-6:00PM

Yes X No

Quest Diagnostics-Boulder PSC 1653 28th Street Boulder CO 80301 303-444-4344 Mon-Fri 8:00AM-12:30PMMon-Fri 1:30PM-3:00PM

Yes X Yes

Tomahawk Truck Stop Cdl Physical and Drug Testing

12060 Sable Blvd Brighton CO 80601 303-659-8895 Sun Mon Tue Wed Thu Fri 8:00AM-6:00PM

Yes X Yes

Quest Diagnostics-Broomfield PSC 799 US Highway 287, Suite F Broomfield CO 80020 303-466-2391 Mon-Fri 8:00AM-12:30PMMon-Fri 1:30PM-3:00PM

No X Yes

CCOM Cannon City 1338 Phay Avenue; CCOM BLDG. Canon City CO 81212 719-285-2800 Mon-Fri 8:00AM-5:00PM Yes X No

Concentra Medical Center 11877 E Arapahoe Rd Centennial CO 80112

Centennial CO 80112 303-792-7368 Mon-Fri 8:00AM-5:00PM Yes X No

Wiz Quiz 2305 E. Arapahoe Road, Suite 147 Centennial CO 80122 303-738-1140 Mon-Fri 9:00AM-5:00PMSat 10:00AM-12:00PM

Yes X Yes

Wiz Quiz 20971 E Smoky Hill Rd 105B Centennial CO 80015 303-400-3172 Mon 1:00PM-6:00PM No X YesKeefe Memorial Hospital 602 N 6th W Cheyenne Wells CO 80810 719-767-5661 Mon-Fri 7:00AM-5:00PM

Sat-Sun 8:00AM-12:00PMYes X No

Colorado Health Services 327 E. Pikes Peak Avenue Colorado Springs CO 80903 719-633-6565 Mon-Fri 9:00AM-5:00PM Yes YesConcentra Medical Center 2322 S. Academy Blvd. Colorado Springs CO 80916 719-390-1727 Mon-Fri 8:00AM-5:00PM Yes NoConcentra Medical Center 5320 Mark Dabling Blvd. Bldg 7

Suite 100Colorado Springs CO 80918 719-592-1584 Mon-Fri 8:00AM-5:00PM Yes No

Quest Diagnostics-Colorado Springs Web

1715 N Weber St Suite 140 Colorado Springs CO 80907 719-636-3707 Mon-Fri 8:00AM-3:30PM Yes X Yes

Compliance Drug & Alcohol Testing 1011 N. Mildred Road Cortez CO 81321 970-565-9515 Mon-Fri 8:30AM-4:30PM Yes X YesFour Corners Drug Testing 641 E. Main St. Unit B Cortez CO 81321 970-564-1443 Mon-Fri 8:00AM-4:30PM Yes X YesMcKey Chiropractic 469 Breeze St. Craig CO 81625 970-824-4444 Mon-Fri 8:00AM-5:00PM Yes X NoThe Memorial Hospital 750 Hospital Loop Craig CO 81625 970-826-2270 Mon-Fri 8:00AM-5:00PM No X NoWiz Quiz - Dacono 209 4th Street, Suite A-z Dacono CO 80514 303-833-2924 Mon-Fri 7:30AM-5:00PM Yes X NoConcentra Medical Center 420 East 58th Avenue, Suite 111 Denver CO 80216 303-292-2273 Mon-Fri 7:00AM-5:00PM Yes X No

Concentra Medical Center 1730 Blake Street, Suite 100 Denver CO 80202 303-296-2273Mon-FRI 8:00AM-6:00PM

Yes X No

Concentra Medical Center 5855 Stapleton Drive North Unit A130

Denver CO 80216 303-371-7444 Mon-Fri 7:00AM-5:00PM Yes X No

Concentra Medical Center 1212 S. Broadway, Suite 150 Denver CO 80210 303-777-2777 Mon-Fri 7:00AM-5:00PM Yes X NoDrug Testing Services, Inc. 1780 S. Bellaire St. Suite 302 Denver CO 80218 303-830-8092 Mon-Fri 8:30AM-5:00PM Yes X Yes

Assigned Collection Site ForUniversity of Colorado Skaggs School of Pharmacy

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8/31/2016

Midtown Occupational Health Services 2420 W 26th AveBldg D, Suite 200 Denver CO 80211 303-831-9393 Mon-Fri 7:00AM-6:00PM Yes X No

Quest Diagnostics-Denver Main Lab 695 S. Broadway Denver CO 80209 303-899-6750 Mon-Fri 7:00AM-5:00PMSat 8:00AM-12:00PM

Yes X Yes

Drug & Alcohol Testing Associates, Inc. 570 Turner Drive, Unit A Durango CO 81303 970-382-9206 Mon-Fri 8:30AM-5:00PM Yes X No

Four Corners Drug Testing 278 Sawyer Dr., #4 Durango CO 81301 970-259-6414 Mon-Fri 8:00AM-12:00PMMon 12:30PM-4:30PM

Yes X Yes

Rocky Mountain Drug Testing 730 W. Hampden Avenue, Suite 200

Englewood CO 80110 720-833-9800 Mon-Fri 8:00AM-5:00PM Yes No

Quest Diagnostics-Ft. Collins Richmond 1100 Haxton Dr Suite 110 Fort Collins CO 80526 970-223-9833 Mon-Fri 8:00AM-3:30PMSat-Sun 8:00AM-11:45AM

Yes X Yes

High Country Health 360 Peak one Dr Suite 260 Frisco CO 80443 970-668-5584 Mon-Fri 8:00AM-4:30PM No X NoConcentra 770 Simms Street, Ste 100 Golden CO 80401 303-239-6060 Mon-Fri 8:00AM-5:00PM Yes NoGrand Valley Occupational Medicine 2004 N 12th Street Grand Junction CO 81501 970-256-6490 Mon-Fri 7:00AM-5:00PM Yes NoCHAMPS @ Greeley Medical Clinic 1900 16th St Greeley CO 80631 970-350-2471 Mon-Fri 8:00AM-12:00PM

Mon-Fri 1:00PM-5:00PMYes No

Medical Services 7257 W 4th Street, Suite #3 Greeley CO 80634 970-351-7447 Mon-Fri 8:00AM-5:00PM Yes NoConcentra Medical Center 9330 South University Blvd. Ste

100Highlands Ranch CO 80126 303-346-3627 Mon-Fri 8:00AM-8:00pm Sat

8:00-4:00PM Sun 10:00-4:00PM

Quest Diagnostics-Quebec PSC 8671 S. Quebec Street, Suite 240 Highlands Ranch CO 80130 720-344-5242 Mon-Fri 10:00AM-3:00PM Yes X Yes

Specimens Unlimited-Mobile Only 30950 County Road 6.5 Lamar CO 81052 719-336-5176 Mon-Fri 8:00AM-5:00PM No NoPlains Medical Center 820 1st St Limon CO 80828 719-775-2367 Mon-Fri 9:00AM-5:00PM

Sat 8:00AM-12:00PMNo X No

Concentra Medical Center 20 W Dry Creek Cir, Ste 100 Littleton CO 80120 303-798-1009 Mon-Fri 8:00AM-5:00PM Yes X NoQuest Diagnostics-Balsam PSC 6179 S Balsam Way, Suite 240 Littleton CO 80123 303-904-9926 Mon-Fri 9:00AM-3:30PM Yes X YesQuest Diagnostics-Longmont PSC 2130 Mountain View Ave. Suite 208 Longmont CO 80501 303-682-9322 Mon-Fri 7:30AM-12:00PM

Mon-Fri 1:00PM-3:00PMYes X Yes

The OIKOS Co 2529 N. Lincoln Ave., Suite C Loveland CO 80538 970-227-9583 Mon-Fri 8:00AM-5:00PM Yes X YesDrug Testing Inc. 26 South Stough Avenue Montrose CO 81401 970-249-1113 Mon-Fri 8:00AM-5:00PM Yes X NoQuest Diagnostics-Northglenn PSC 11310 N. Huron St Ste 220 Northglenn CO 80234 720-929-2433 Mon-Fri 8:00AM-4:30PM

Sat 8:00AM-12:00PMYes X Yes

CCOM Pueblo 4112 Outlook Blvd Suite 255 Pueblo CO 81008 719-562-6300 Mon-Fri 8:00AM-4:30PM Yes X NoEmergiCare 4117 North Elizabeth Pueblo CO 81008 719-545-0788 Mon-Fri 8:00AM-6:00PM

Sat 8:00AM-2:00PMYes X No

Quest Diagnostics-Pueblo Lake Ave PSC

1910 Lake Ave Pueblo CO 81004 719-566-3518 Mon-Fri 8:00AM-12:00PMMon-Fri 1:30PM-4:00PM

Yes X Yes

Rangely District Hospital 225 Eagle Crest Drive Rangely CO 81648 970-675-5011 Mon-Fri 7:30AM-5:30PM Yes NoA1 Drug & Alcohol Screening 1433 Airport Rd. Rifle CO 81650 970-274-2023 Mon-Fri 7:00AM-5:00PM Yes NoThe Drug Testing Place Inc. 1530 Railroad Ave, Suite A Rifle CO 81650 970-625-3033 Mon-Fri 8:00AM-5:00PM Yes YesSteamboat Medical Group 1475 Pine Grove Rd, Ste 102 Steamboat Springs CO 80487 970-879-0203 Mon-Fri 8:00AM-7:00PM

Sat 9:00AM-2:00PMSun 9:00AM-12:00PM

Yes No

Sterling Regional Medical Ctr (SRMC) 615 Fairhurst St Sterling CO 80751 970-521-3128 Mon-Fri 9:00AM-11:00AMMon-Fri 1:00PM-4:00PM

Yes No

Concentra Medical Center 500 E. 84th Ave. Suite B14 Thornton CO 80229 303-287-7070 Mon-Fri 8:00AM-5:00PM Yes NoDrug Techs LLC 51 W 84th Ave #304 Thornton CO 80260 303-650-4151 Mon-Fri 8:30AM-4:30PM Yes X Yes

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