Pharmacy Site & Preceptor Enrolment Form
Office of Experiential Education, Faculty of Pharmaceutical Sciences, UBC

Please begin by saving this document on your computer and then type your responses in the shaded boxes. Save your completed form. Email completed form to or print and fax to: 604-822-3035.

For access to preceptor resources and updates, please visit us at:

Date completed:dd/mm/yyyy

Pharmacist’s Name:

Last:First:

Title: MrMs MissMrs DrEmployment Title:

Preferred Clerkship: (select all that apply) 2nd year 3rd year 4th year IPG Technician

Pharmacy Degrees Obtained:

(a) UndergraduateYear: Institution:

(b) Postgraduate qualificationYear: Institution:

Additional Degrees/Diplomas/Certificates:

# Hours worked at this site/week: BC Pharmacist License #:

Manager’s Name: (if different)

Last: First:

Title: MrMs MissMrs Dr

Manager’s Phone: Fax: Email:

Pharmacy Name: Store Number (if relevant):

Site Address: City: Postal Code:

Business Phone: Fax: Email:

Hours of Operation:

Describe your Practice Setting Type (select all that apply):

Aboriginal Health Practice

Acute Care Hospital # of beds:

Ambulatory Care Clinic

Community Pharmacy

Long Term Care Facility associated with Health Authority # of beds:

Nursing Home Vendor

Rural/Underserved Practice

Other Please Describe:

Site Services Available (select all that apply):

Brace Fitting

Complementary Alternative Medicine

Compounding If yes, # per week: Types (eg. hormone replacement):

Dedicated Patient Consultation/Counselling Area

Discharge Counselling

Home Health Care

Home Visits

Immunizations

Lab Value Interpretation

Ostomy Supplies

Pharmacokinetic Monitoring

Patient Monitoring Service (e.g. blood glucose, blood pressure)

Other Please Describe:

Ongoing Disease & Drug Management program(s) Available:

Anticoagulation Monitoring

Arthritis Screening

Asthma

Diabetes

HIV

Hormone Replacement Therapy

Hypertension

Hypercholesterolemia

Mental Health

Methadone Maintenance

Nutrition

Oncology

Opioid Dependency

Pain Management

Renal

Smoking Cessation

Other Please Describe:

Preferred spoken language(s) of learners at your site:

1. Your Practice
Yes / No
  1. OEE activities concentrate on developing students’ abilities to conduct direct patient care (specifically, Pharmaceutical Care). Does your practice incorporate the Pharmaceutical Care Process (assessment, care plan and follow-up)?

  1. In your practice setting is there a sufficient number of patients for students to gain proficiency in direct patient care?

  1. Is your physical practice environment conducive to student provision of all aspects of Pharmaceutical Care? (eg. private counselling area, workflow/space that will accommodate student activities)

  1. Is there sufficient opportunity for the student to meet OTC product counselling learning objectives?

  1. Is there sufficient physical space to accommodate student(s)?

  1. Is there sufficient staffing to facilitate pharmacist/student provision of consistent direct patient care?

  1. Will the student have Internet access at the site?

  1. Are there opportunities for the student to practice collaboratively with other health care providers?

  1. Comments related to any of the above items:

2. Preparation for OEE
Yes / No
  1. To prepare for the responsibilities of teaching, coaching and assessing students, the Faculty requires practitioners to participate in a preceptor development program. Are you prepared to participate either in person at the Faculty, or via an online educational session?

  1. I have discussed the pharmacy practice experiences with, and gained support from, my manager to have student(s) on site and we agree that I will be able to fulfil the preceptor role.

c. Comments on any of the above items:
3. Your Teaching
  1. List previous teaching experience(s) or preceptor training you have undertaken (may be pharmacy or non-pharmacy related).

  1. Briefly describe your established past or envisioned future approach to teaching students:

4. Your Interest
What prompted you to apply to become a preceptor?

Provide any other information or comments pertinent to your application.

Please save/make a copy for your records and then send the completed form to: or fax: 604-822-3035.

A Student Placement Agreement (SPA) is required by the Canadian Council for Accreditation of Pharmacy Programs (CCAPP). These are currently in place for all health authorities and many pharmacy sites. If the SPA has expired or does not exist for your site, we will need to contact the pharmacy owner.

Experiential Site and Practice Educator Requirements

The Practice Educator:

The FoPS UBC will strive to identify practice educators who will be positive role models for students and who, in general, demonstrate the following behaviour, qualities, and values (as applicable to their area of practice):

  • Practice ethically and with compassion for patients
  • Accept personal responsibility for patient outcomes
  • Have professional training, experience, and competence commensurate with their position
  • Utilize clinical and scientific publications in clinical care decision making and evidence-based practice
  • Have a desire to educate others (patients, care givers, other health care professionals, students, pharmacy residents)
  • Have an aptitude to facilitate learning
  • Be able to document and assess student performance
  • Have a systematic, self-directed approach to their own continuing professional development
  • Collaborate with other health care professionals as a member of a team
  • Be committed to their organization, professional societies, and the community

Practice Educator Criteria

In selecting and assigning practice educators the Office of Experiential Education will preferentially assign students to pharmacists and other healthcare professionals who:

  • Are in good standing with the CPBC or respective regulatory body;
  • Demonstrate mentorship and professionalism;
  • Demonstrate empathy and caring for patients;
  • Ensure adequate individualized instruction, guidance, supervision and assessment of learner at each site;
  • Have exceptional teaching skills;
  • Have exceptional clinical skills;
  • Have a minimum of six months experience in direct patient care activities;
  • Provide students with opportunities to provide comprehensive patient care;
  • Spend at least 30% of their time in direct patient care activities;
  • Spend at least 50% of their time with the learner, if the primary preceptor; and
  • Provide formative and summative feedback on learner performance using the required assessment guide and evaluation form.

Evaluation of Practice Educators

Assigned students will evaluate preceptors and their practice sites. The results of the student evaluations will be communicated to the head office/regional office/HA coordinator or practice educator annually.

The Experiential Site:

The FoPS UBC will strive for all sites to have the potential for excellence. Students will be placed preferentially at sites that demonstrate excellence and advance the profession.

  • The site should maintain adequate staffing to allow the student a meaningful educational experience.
  • The site should meet all standards set by accrediting bodies.
  • The site and its staff should be free of any violations of provincial and/or federal laws.
  • The site should be clean and reflect a professional image.
  • All pharmacists at the site must maintain an outstanding ethical and legal compliance record.
  • One pharmacist at the site shall be designated the primary practice educator to supervise student learning at the site. Other pharmacists may co-preceptand support student learning if they meet the practice educator criteria.
  • The practice setting must provide sufficient scope of pharmaceutical services with the volume and variety of activities suitable to provide a rich learning environment. ,
  • Sufficient reference materials and internet access should be available for the provision of information to patients, pharmacists, and other health professionals.

Practice Educator Agreement

I accept the responsibility of being a practice educator for PHAR 369 / 469 / 479 / 489 (please circle one), a required course at the FoPS UBC.

By signing this form I agree to: (please check off boxes)

Provide the learner with an orientation to the facility and pharmacy staff.

Ensure appropriate patient care opportunities are provided to the learner to complete the required learning activities.

Ensure ongoing formative feedback is provided to the learner on a daily basis to improve the learner’s knowledge and skills.

Provide regularly scheduled weekly meetings to discuss and review the mandatory learning activities and the learner’s progress on achieving these.

Complete all mid-rotation and summative final evaluations for the learner as required.

Communicate any difficulties with the course or learner with the Office of Experiential Education as soon as they arise.

Disclose any relationship that may create a conflict of interest as soon as the potential conflict or bias is identified. Situations requiring disclosure include the existence of any personal relationships (e.g. family friend, familial relationships) and the existence of any financial or business connections (e.g. previous, current or future employment).

Complete foundational preceptor training – see Practice Educator Resources on

If you as a pharmacist or pharmacy manager have been the subject of a formal complaint brought before the inquiry committee in the last five years, please provide full details and a copy of the inquiry complaint disposition letter or discipline committee findings (please circle one):

Yes, documentation attached No, not applicable

I declare that I have no perceived or actual conflicts of interest and I am in good standing with the College of Pharmacists of BC.

Name: Email address:

Signature:

Manager Agreement

I agree to support the pharmacist above in his/her efforts to provide the learner with an optimal learning experience.

Name: (Print)Email address:

(If same as above please indicate)

Signature:

PLEASE FAX COMPLETED FORM TO 604-822-3035 ATTN: Office Experiential Education or Email to

Faculty Administrative Use only:

Date received: Coordinator initials:

Comments / issues to clarify:

Entered in database: YesNo Student Placement Agreement: SentReceived

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