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Pharmacist Intern Application

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Waiver of Fee -- Determination of Eligibility

An applicant for an initial license or registration is eligible for a waiver of the initial fee(s) if the applicant’s adjusted gross household income does not exceed 200% of the Federal Poverty Level and the applicant is applying for this specific license/registration category for the first time.

To determine eligibility, you must first identify the number of individuals in your household. Once this is determined, reference the Federal Poverty Level and identify your adjusted gross income that matches the number of individuals in your household. If your adjusted gross household income, as reported on your most recent federal tax return, is less than the identified value, you are eligible for the one-time fee waiver.

If you determine that you are eligible for the one-time fee waiver, you will be provided an opportunity to request the waiver at the end of this application. You will also be required to upload a copy of your household Federal Tax Return for the preceding year.

If you are married and filed separately, you will need to submit the Federal Tax Return for both your spouse and yourself.
If you were claimed as a dependent on another person’s tax return, you will need to submit the Federal Tax Return for the tax filer who claimed you as a dependent.

Please be sure you have the required documents ready before proceeding with this application. If your documents are not available for upload when the waiver opportunity is presented, you will need to redo this entire application to request a fee waiver.

Pharmacist-Intern (Intern)

You are applying for a Pharmacist-Intern (Intern) registration. An Intern registration is required before a student begins their internship training/rotations, but not before the commencement of the first professional year in a college of pharmacy. The fee for a pharmacist-intern registration is $30. There is a $2 convenience fee for online registration using a credit or debit card to make payment. Application fees are nonrefundable administrative fees.

The “Certificate of Eligibility” form is to be completed by the College of Pharmacy and submitted directly to the Iowa Board of Pharmacy office. The intern registration will not be issued until the “Certificate of Eligibility” is received.

Registrations are issued administratively following review of a completed application and all required documentation, unless the application warrants referral to the Board, or unless a personal appearance is required.

Applications are valid for only 45 days from the date of receipt. You will be notified by email if additional information is required. If the application has not been completed within 45 days, a new application and fee will need to be submitted if you wish to obtain an Iowa intern registration.

Failure to answer all questions completely or accurately, and/or omission or falsification of material facts may be cause for denial of your application, or disciplinary action if you are subsequently registered by the Board. If you are in doubt, answer “yes” and provide an explanation.

Pharmacist-Intern Application

Be advised that this application for pharmacist-intern registration asks about any medical conditions you have that might impair your ability to perform the duties of a pharmacist-intern. As part of the application process you will be asked questions about any recent criminal history and disciplinary actions.

If you have any questions concerning these requirements, please contact the Board office. We suggest you contact the Board office for information as to what documentation may be necessary for registration. Contacting the Board office about any of these situations may avoid unnecessary delays with your application.

Definitions

Important! Read these definitions before completing this application.

“Ability to perform required pharmacist-related tasks with reasonable skill and safety” means ALL of the following:

The cognitive capacity to use pharmacy systems to obtain necessary patient and prescription related information to process prescriptions

The ability to effectively communicate information to pharmacists, interns, providers, technicians, pharmacy support persons, and patients

The ability to perform required tasks such as filling prescriptions, counseling patients, performing drug utilization reviews and other professional pharmacy services

“Medical condition” means any physiological, mental, or psychological condition, impairment, or disorder, including drug addiction and alcoholism.

“Chemical substances” means alcohol, legal and illegal drugs, or medications, including those taken pursuant to a valid prescription for legitimate medical purposes and in accordance with the prescriber’s direction, as well as those used illegally.

“Improper use of drugs or other chemical substances” means ANY of the following:

The use of any controlled drug, legend drug, or other chemical substances for any purpose other than as directed by a licensed health care practitioner; and

The use of any substance, including but not limited to, petroleum products, adhesive products, nitrous oxide, and other chemical substances for mood enhancement.

“Illegal use of drugs or other chemical substances” means the manufacture, possession, distribution, or use of any drug or chemical substance prohibited by law.

“Currently” does not mean on the day of, or even in weeks or months preceding the completion of this application. Rather, it means recently enough so that the use of chemical substances or medical conditions may have an ongoing impact on the ability to function and perform the duties required of a pharmacist-intern, or has adversely affected the ability to function and perform the duties required of a pharmacist-intern within the past two (2) years.

Internship Requirements

Internship shall consist of a minimum of 1500 hours, all of which may be a college-based clinical program approved or accepted by the Board.

A pharmacist-intern registration is required before beginning any training, including a college-based clinical program.

A pharmacist-intern may acquire additional hours under the supervision of one or more preceptors in a traditional licensed general or hospital pharmacy, at a rate of no more than 48 hours per week, during periods when the intern is not attending classes (official school breaks).

Credit towards any additional hours will be allowed, at a rate not to exceed 10 hours per week, for an internship served concurrent with academic training and outside a college-based clinical program.

Iowa Regulations

657 Iowa Administrative Code Chapter 4 Pharmacist-Interns governs the practice of an intern in an Iowa pharmacy.

Have you reviewed and do you understand the Iowa regulations pertaining to interns?

Yes

Required Documents

A Government-Issued Photo Identification (driver’s license, government issued ID, passport, etc.) is required to be uploaded with your application.

In addition, the following documents may be required to be uploaded with your application:

1. Description and documentation of the conviction(s) for any criminal history disclosed. (Do not attach summaries or docket print outs from Iowa Courts Online).
a.You are strongly encouraged to perform a background check on yourself or to have your employer perform one prior to submitting your application. To search Iowa Courts online go to https://www.iowacourts.state.ia.us and click “Start a Case Search Here.” Keep in mind that this database only shows Iowa state court convictions. These instructions are not intended to provide a comprehensive criminal history background check, but rather a quick way for you to refresh your memory as to any Iowa state court convictions.
2. Description and documentation of the final disciplinary order(s) for any disciplinary history disclosed
3. Description and documentation of the final denial order(s) by a licensing authority.

Military or Veteran Status

1.Are you active duty military?

Yes

2.Are you a military veteran?

Yes

3. Are you the spouse of a active duty military member or veteran?

Yes

Prior Iowa Board of Pharmacy Licensure or Registration

Have you ever been licensed or registered with the Iowa Board of Pharmacy in any capacity?

Yes

Full Name

Street Address

C S Z

License #

Personal Information

Provide Full Legal Name

If your name has changed since your previous license or registration, upload a copy of the legal name change document (marriage certificate, divorce decree, legal name change petition) and staff will update the information upon review of the application.

Provide Full Legal Name

Last Name

First Name

Middle Name

Suffix

Maiden Name/Previous Name(s) Used

Date of Birth

Social Security # or ITIN

Gender

NABP E-Profile ID number

If you do not have an NABP E-Profile ID number, you may create one by clicking here.

Has your name changed since your previous license or registration?

Yes

Document Type

Attach Name Change Document

Home/Permanent Address

Address 1

Address 2

Address 3

Country

Zip

City

State

County

Alternate Mailing Address (optional)

Check if mailing address is the same as physical address

Address 1

Address 2

Address 3

Country

Zip

City

State

County

Intern Contact Information

Phone Type

Primary Phone #

Accept Text Message

Yes

Alternate Phone Type

Alternate Phone # for Facility

Accept text message

Yes

E-mail

Fax #

College of Pharmacy

Name of college of pharmacy

Date enrolled in college of pharmacy

Upload FPGEC Certificate

Anticipated date of graduation or date of degree

Date internship training will begin

Internship Site

Do you currently have a preceptor and an internship practice site that is not part of the college of pharmacy clinical rotations?

Yes

Current Employment

Are you currently employed in a licensed Iowa pharmacy other than a preceptor site previously identified?

Yes

Other State Licenses or Registrations

Do you or have you ever held a professional license/registration in Iowa or another state (this does not include drivers’ licenses)?

Yes

Criminal History

Have you ever been convicted of or entered a plea of guilty, nolo contendere, or no contest to a misdemeanor or felony crime in any jurisdiction? All convictions, except for minor traffic offenses, must be disclosed. Conviction means a finding, plea, or verdict of guilt made or returned in a criminal proceeding, even if the adjudication of guilt is deferred, withheld, or not entered. Conviction includes Alford pleas and pleas of nolo contendere. You must submit the complaint and judgment of conviction for each offense and a personal statement regarding whether each conviction directly relates to the practice of pharmacy. Your application will not be considered complete until the entirety of this information is received by the Board.

Yes

Disciplinary Actions/History

Have you ever been disciplined by any licensing authority? Discipline includes, but is not limited to, citations, reprimands, fines, license or registration restrictions, probation, suspension, revocation, or surrender.

Yes

Professional License/Registration Denials

Have you ever been denied a license or registration by any licensing authority?

Yes

Pending Investigations

Do you have any charges, or knowledge of any investigations or complaints, pending before any licensing authority?

Yes

Required Documents

Illegible copies will not be accepted.

Upload a copy of Government Issued Identification (driver’s license, government issued ID, passport, etc.)

Acknowledgement

I am aware that I cannot legally compound or dispense drugs or provide patient counseling except when I do so under the immediate and personal supervision of a licensed pharmacist and I understand that I may not be left in charge of a pharmacy.

I acknowledge that it is my responsibility to timely report any change of name, address, or employment status within 10 days of a change.

Preview

Please review your application and return, using the Previous button, to any page(s) that needs to be changed or corrected.
Once you click the Next button on this page you will not be able to make any changes to your application.

Confirm and Submit

I hereby swear or affirm under the penalty of perjury that the information provided in this application is true and correct. I understand that failure to provide complete and truthful information may constitute grounds for denial, revocation, or other disciplinary sanctions against my pharmacist-intern registration. Information provided on this application may be disclosed pursuant to 657 IAC Chapter 14, subject to exceptions in federal and state law.

Signature

Date

License/Registration Type

State Licensing Body

License/Registration number

License/Registration Status

License/Registration issue date

License/Registration expire date

License Type

License Number

Business Name

Address

Zip

City

State

Name of the PIC

Pharmacy email address

Exact date of hire as a Intern, when you began working as a Intern in the secured pharmacy area

Pharmacy License No

Pharmacy Name

Address 1

Address 2

Zip

City

State

Telephone #

Date you start(ed) practicing as an intern at this location

You must provide copies of all related court documents relating to the conviction. Submitting printouts from Iowa Courts Online is not sufficient.

You must provide copies of all final disciplinary orders issued.

You must provide copies of all final denial orders issued.