1. Office of Experiential Education Student Data and
Release Authorization Form
Dear CSU-COP Student:
In the course of your educational experience at Chicago State University College of Pharmacy,
the College may need to provide personal student information (date of birth, social security
number, immunization records, health records, criminal background check results, drug
screening results, etc.) to our practice partners in conjunction with the placement of students
for experiential education opportunities. The “Office of Experiential Education Student Data
and Release Authorization Form” will be used to collect some of this information. Please
complete the form, on the second page of this document, as instructed.
Additionally, by signing the “Office of Experiential Education Student Data and Release
Authorization Form ” you are granting the College permission to release personal student
information (date of birth, social security number, immunization records, health records,
criminal background check results, drug screening results, etc.) to our practice partners as
specified by the request of our practice partners.
Should you have any questions or concerns, please contact Dr Charisse Johnson, Director of
Experiential Education, at 773-821-2587 or at c-johnson@csu.edu.
Please clearly print all responses on the next page.

2. Instructions – Please print all responses.
CSU ID#________________________________ Expected Graduation Date_____________________
Current Address:_________________________ City______________ State________ Zip__________
First Name: _____________________________ Last Name: _________________________________
CSU E-Mail Address: ______________________ _ Secondary E-Mail Address: _____________________
IL Tech License Number: ____________________ Social Security Number: _______-_______-________
Date of Birth (MM-DD-YYYY) ________________ Gender (Mark “X”) Male ______ Female _______
I decline to provide my social security number. I acknowledge that not providing this information may result in the inability to complete the
didactic and experiential requirements of the program and therefore graduating from Chicago State University College of Pharmacy.
Transportation
Do you reside on campus? (Mark “X”) Yes_____No_____
Do you use public transportation? (Mark “X”) Yes_____No_____
Please list all current and/or previous pharmacy work (volunteer) experience below.
If additional space is necessary, please continue on the back of this document.
Company/Facility: From: To:
Company/Facility Address: Position/Title:
City, State Zip: Name of Supervisor:
Duties:_______________________________________________________________________________________________
Company/Facility: From: To:
Company/Facility Address: Position/Title:
City, State Zip: Name of Supervisor:
Duties:____________________________________________________________________________________________________________________________
Language(s) Fluent in Speaking and/or Writing (Other than English):
_______________________________________________________________________________________________________________________
Release Authorization of Confidential Records
Confidential records include all immunization records, health records, criminal background checks results and drug screen results, etc. and including
content within the Office of Experiential Education Student Data and Release Authorization Form.
I __________________________________________________ (Print Name) authorize the Office of Experiential Education to release my confidential
records to practice partners for experiential education opportunities. I do understand that should any practice partner have concerns regarding
the content of my confidential records, this may affect my ability to complete experiential education at the site and therefore the completion and
graduation from the CSU-COP program.
_____________________________________ _____________20______
Student Signature Date
Office of Experiential Education Student Data and
Release Authorization Form