2020 USPHS PharmPAC Student Award Application
Instructions:Complete all the sections of the USPHS Excellence in Public Health Pharmacy Award application (general information, brief citation, and narrative)Save the document as: USPHS_StudentAwardApplication_LastName_FirstName and send it as an email attachment. Email the completed application to CDR Sadhna Khatri at: USPHSPharmacyAward@fda. no later than December 31, 2019.A confirmation of receipt will be sent via e-mail to your school within 5 business days after submission. If you do not receive confirmation, please contact CDR Sadhna KhatriUSPHSPharmacyAward@fda.. The school will be notified by March 31, 2020 of the status of the award.Reminder: Only one pharmacy student from each school or college of pharmacy can be nominated. The nominee’s achievements must extend beyond school requirements. Nominations will not be accepted if the work is part of the student’s required curriculum; this includes the required Introductory or Advanced Pharmacy Practice Experiences.General Information:Publication:Grant permission to publish student award (e.g., PharmPAC website or other online publication)? ?Yes or ?NoStudent Information:Student Name: FORMTEXT ?????Street Address: FORMTEXT ?????City: FORMTEXT ?????State: FORMTEXT ??Zip: FORMTEXT ?????Name of Pharmacy School/College: FORMTEXT ?????Student’s Year of Graduation: FORMTEXT ?????Nominator Contact Information:Nominator: FORMTEXT ?????Nominator’s Title: FORMTEXT ?????Street Address: FORMTEXT ?????City: FORMTEXT ?????State: FORMTEXT ?? Zip: FORMTEXT ?????Email Address: FORMTEXT ?????Phone Number: FORMTEXT ?????Presentation of Award:Date and Time of Award Presentation: FORMTEXT ?????Location of Award Presentation: FORMTEXT ?????Street Address: FORMTEXT ?????City: FORMTEXT ?????State: FORMTEXT ?? Zip: FORMTEXT ?????Contact Person at the School/College (person that the award will be sent to):Name and Title: FORMTEXT ?????Street Address: FORMTEXT ?????City: FORMTEXT ?????State: FORMTEXT ?? Zip: FORMTEXT ?????Email Address: FORMTEXT ?????Phone Number: FORMTEXT ?????Brief Citation (25 words or less stating what the student accomplished): FORMTEXT ?????Nomination NarrativePlease DO NOT exceed two single-spaced, typed pages.AccomplishmentThis section should briefly summarize the accomplishment and its impact.BackgroundThis section is designed to give background information to the PharmPAC Student Awards Team who reviews all nominations. This section should include information about the nominee and any information necessary to understand the nominee’s accomplishment.InterventionThis section should state the specific action(s) of the accomplishment. This paragraph should explain what the student did to achieve this accomplishment. While not necessary, a bulleted list is an acceptable way to present the information in this section.OutcomeThis section should detail the impacts of the nominee’s accomplishment, with a focus on the impacts of the accomplishment on public health. This section should be clear and definite. While not necessary, a bulleted list is an acceptable way to present the information in this section. ................
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