INSTRUCTIONS: You must provide the following information, including the name(s) of the school(s) with which you have been involved in any activities, as well as your preferred Email address. (Note: To select multiple schools, press and hold your Control Key while clicking your left mouse button.)

Albany College of Pharmacy Auburn University Butler University Campbell University Creighton University Drake University Duquesne University Ferris State University Florida A&M University Hampton University Howard University Idaho State University Lake Erie College of Osteopathic Medicine Loma Linda University Long Island University Mass. College of Pharmacy at Boston Mass. College of Pharmacy at Worcester Medical University of South Carolina Mercer University Midwestern University at Glendale Midwestern U, Chicago College of Pharmacy Nevada College of Pharmacy North Dakota State University Northeastern University Nova Southeastern University Ohio Northern University Ohio State University Oregon State University Palm Beach Atlantic College Purdue University Rutgers University Samford University Shenandoah University South Dakota State University South University Southwestern Oklahoma State St. John's University St. Louis College of Pharmacy State University of New York at Buffalo Temple University Texas A&M University Texas Southern University Texas Tech University University of Arizona University of Arkansas University of California at San Diego University of California at San Francisco University of Cincinnati University of Colorado University of Connecticut University of Florida University of Georgia University of Houston University of Illinois at Chicago University of Iowa University of Kansas University of Kentucky University of Louisiana University of Maryland University of Michigan University of Minnestota University of Mississippi University of Missouri University of Montana University of Nebraska University of New Mexico University of North Carolina University of Oklahoma University of Pittsburgh University of Puerto Rico University of Rhode Island University of South Carolina University of Southern California University of Tennessee University of Texas University of the Pacific University of the Sciences in Philadelphia University of Toledo University of Utah University of Washington University of Wisconsin University of Wyoming Virginia Commonwealth University Washington State University Wayne State University West Virginia University Western University of Health Sciences Wilkes University Wingate University Xavier University of Louisiana

INSTRUCTIONS: Complete this section to report any visit, event, or other activity at your school, including the name and position of your primary contact, along with any important details. You may complete and submit this form multiple times to report multiple visits/events/activities, as necessary.

If you answered Yes to Question 2, please complete the remaining items. Otherwise, leave the items blank and submit the form only once.

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