Pharmacy Informatics Workgroup 12 Va salt lake city hcs SAMPLE 2 Trainee information sheet TRAINEE’S NAME __________________________________ EXPECTED EOD: ____________________________ SSN: ___ _-____-______ PHONE NO: (801) __________________________ ADDRESS: George E Wahlen VAMC___ 500 Foothill Drive________ Salt Lake City, UT 84148__ AFFILIATE: VA Salt Lake City Health Care Center PRECEPTOR ____Lezlie Cohn-Oswald______________________EXTENSION: 4208 PROGRAM DIRECTOR: Debra Macdonald___________________EXTENSION: xxxx PROGRAM PRECEPTOR: Jeremy Hotelling (OP)___________EXTENSION: xxxx PROGRAM PRECEPTOR: Lynette Rynearson___(IP)___________ EXTENSION: xxxx x WOC APPOINTMENT X - PHARMACY TECHNICIAN EXTERN Beginning Date: ______________________ Ending Date: ___________________________ Total Hours: ____180-Pharmacy Tech Extern_____ Hours Per Pay Period: _____N/A_______________ __ PAID APPOINTMENT ( Check Box Below ) Beginning Date: __________________________ Ending Date: _____________________________ Total Hours: ______________________________ Hours Per Pay Period: ____________________ ⁫ GRECC – Subaccount 1053 ⁫ Podiatry - Subaacount 1077 ⁪ Audiology & Speech Pathology (Masters) ⁪ Podiatry – Surgery (Resident) ⁪ Nursing – Nurse Practitioner (Trainee – 320 hrs) ⁪ Nursing – Nurse Practitioner (Trainee – 120 hrs) ⁫ PRIME – Subaccount 1051 ⁪ Occupational Therapy (Trainee)⁪ Nursing – Nurse Practitioner ⁪ Optometry (Resident)⁪ Occupational Therapy (Trainee) ⁪ Physical Therapy (Trainee)⁪ Pharmacy (Resident) ⁪ Psychology (Intern Level (II)⁪ Physical Therapy (Trainee) ⁪ Social Work (Masters)⁪ Physician Assistant (Trainee) ⁪ Podiatry - Surgery (Resident) ⁫ Advanced Practice Nurse - Subaccount 1051 ⁪ Psychology (Intern Level II) ⁪ Nursing – Clinical Nurse Specialist (Trainee)⁪ Social Work (Masters) ⁫ Dentistry – Subaccount 2587 ⁫ Psychology – Subaccount 1051 ⁪ Dentistry – General Practice (Resident)⁪ Psychology (Intern Level II) ⁫ Occupational Therapy – Subaccount 1051 ⁫ Social; Work – Subaccount 1051 ⁪ Occupational Therapy (Trainee)⁪ Social Work (Masters) ⁫ Pharmacy – Subaccount 1051 ⁫ Physical Therapy – Subaccount 1051 ⁪ Pharmacy (resident) ⁪ Physical Therapy (Trainee)