Name
EXAMPLE:
Smith, Jane

Professional Pharmacy Degree(s)
EXAMPLE:
B.S., M.B.A.

Academic Title
EXAMPLE:
Clinical Assistant Professor, UW
School of Pharmacy

Practice Location
EXAMPLE:
HMC Ambulatory Pharmacy or
UWMC-Roosevelt; HMC 4-West
Pharmacy, Pioneer Square, etc.

Job Title
EXAMPLE:
Clinical Pharmacist or Night Shift
Lead Pharmacist, etc.

Clinical Team Assignment; Special Program
or Administrative Responsibilitie(s) - optional
EXAMPLE:
Pyxis System, DUEs, Eye Center
Pharmacy Liaison, etc.

Specialty Practice Interest(s)
EXAMPLE:
Intensive Care, Pain Management,
Oncology, etc.

Education (degree, school, city, year graduated)
EXAMPLE:
B.S., Pharmacy, Oregon State University, Corvallis, 1981;
Doctor of Pharmacy, University of Washington, Seattle, 1983

Advanced Pharmacy Training (type, institution, city, year)
EXAMPLE:
General Residency, University of Washington Medical Center,
Seattle, 1981-83
Specialized Residency, Primary Care, Harborview Medical
Center, Seattle, 1983-84

Professional Affiliations (type, association)
Example Format:
Member, American Diabetes Association; Member, Seattle
Area Society of Health System Pharmacists; Past President,
WSSHP

Certifications (type, year)
Example Format:
Registered Pharmacist,; ACLS Certified, 1999; Certified
Diabetes Educator, 1990; etc.
Registered Pharmacist

Year Joined Department of Pharmacy Services
Example Format:
1995

"Home-Base" Location
Select One Hall Health Center HMC HMC-Pioneer Square UWMC UWMC-Roosevelt UWMC-SE Lake Union Other

Current "Practice Grouping"
Select One (if "other" or >1 use box below to describe) Administration Anticoagulation Asthsma Cardiology/Cardiac Surgery Diabetes Drug Information Drug Services Hall Health Center Pharmacy Home Care Infectious Diseases/HIV Information Systems Intensive Care Inpatient (Central) Pharmacy Investigational Drugs Medicine Neurology/Neurosurgery/Neurosciences Oncology Operating Room Pharmacy Satellite Orthopedics Outpatient (Central) Pharmacy Psychiatry Purchasing Refill Center Residents Surgery Women/Children's Health Other

"Other" Current Practice Grouping

What you find most rewarding about your work with patients at
the UW or HMC - optional

Other - optional
Example:
Your current clinical team assignment(s)
The patient care areas for which you are responsible
Special committee work you'd like recognized

Photograph - optional
Do you have a photograph you'd like included with your bio or
would you like to schedule a time to be photographed?
(If yes, you will be contacted to make the arrangements.)