SHEPS CENTER DATA REQUEST FORM
NC Health Professions Data
Pharmacist Data
Fill out this form, print, and fax it to:
NC Board of Pharmacy
6015 Farrington Road, Suite 201
Chapel Hill, NC 27515-4560
Dr. David Work, Executive Director
Phone: (919) 942-4454
Fax: (919) 967-5757

Attach a separate page describing the intended use for the labels/listing. Once approval has been received by the Sheps Center, you will be contacted with an estimated price and delivery date of the output. Contact the Sheps Center Data Coordinator at nchp@unc.edu or (919)966-7112 if you have questions or need additional information.

NOTICE: Data are provided by the NC Board of Pharmacy as of October each year and compiled by the Sheps Center. Address changes are made only at the time of the annual update. Contact the Sheps Center Data Coordinator at (919) 966-7112 for more detailed information regarding the Sheps Center files.

Requester's Name:
Business Name:
Address:
City, State & ZIP:
Telephone Number:
Fax Number:
Email Address:
Type of Organization: For-Profit (FP)     Non-Profit (NP)

Electronic Output Request Type: Check one or more
Name, address, specialty, county ($4.50/100 names: $100.00(NP)/$200(FP) minimum)
All data available ($7.00/100 names: $200.00(NP)/$300(FP) minimum)

Output format:
 Tab-delimited Comma-delimited Fixed Field
Other (please specify):

SELECTION CRITERIA (check all that apply):

Activity Status: Active   Inactive

Area Selection: In-state   Out-of-state
Specific counties:
Other (please specify)

Practice Setting:
Unknown
Industry
Chain
Nursing Home
Hospital
Government
Manufacturing
Teaching
Other
Sales
Research
Health Department

Form of Employment:
Unknown
Sole Owner-Manager
Partner/Manager
Partner/Non-manager
Supervisor
Pharmacy Manager-Employee
Staff-Pharmacist
Unpaid Worker
Sales-Pharmaceutical
Manufacturing-Pharmaceutical
Relief Pharmacist
Other

Description of Request: List other details of your request in the box below.


What order do you want the output sorted in?

For NC Board of Pharmacy Use Only:
Approved by:______________________________________________  Date:________

Note to Board: Please send this form with approval to the Sheps Center Data Coordinator:
Fax (919) 966-5764.

Updated 5/1/05