Student to Complete Top Portion and Preceptor to Complete Lower Portion
Office of Experiential Education
Early Practice Experience (EPE) - Site Request Form
Student to complete top portion and preceptor to complete lower portion.
(Please complete by TYPING directly on the form )
STUDENT TO UPLOADFORM IN RXPRECEPTOR. Student & Preceptor will receive confirmation by email.
Student to complete this section:
Student Name::Click here to enter text.Student IDNumber: __Click here to enter text.Course: EPE-1: EPE-2:
Date Form Completed:Click here to enter a date.
Preceptor to Complete & Sign: (PLEASE COMPLETE BY TYPING DIRECTLY ON THE FORM):
Dr. Mr. Ms. Miss Mrs.
Preceptor Name: Click here to enter text.Preceptor EmailClick here to enter text.
Site NameClick here to enter text.Store #Click here to enter text.Phone #Click here to enter text.
Site Address: Click here to enter text.City:Click here to enter text.Postal CodeClick here to enter text.
Rotation (160 hours) Dates: (specific start and end date to fall within May 1st to August 25th2017): Click here to enter text.
Comments for the Experiential Office: Click here to enter text.
Preceptor Agreement
I accept the responsibility of being a preceptor for (student name) in: Click here to enter text.
EPE-1 or EPE-2
By signing this form I agree to (each of the following):
- Familiarize myself with course requirements and responsibilities of a preceptor by reviewing course documents
- Ensure appropriate learning opportunities are provided to allow the student to practice and demonstrate competency in theEPE 1 and 2 course requirements
- Ensure opportunities for ongoing formative feedback are provided to the student,on a frequent (e.g.daily) basis,by the pharmacist(s) responsible for the learning activities.
- Provide weekly meetings to discuss and review the learning activities and the student’s progress on achieving these.
- Discuss and complete the mid-pointand final assessment forms
- I declare I have no perceived or actual conflicts of interest and I am in good standing with the Ontario College of Pharmacists
Preceptor OCP # (or equivalent if out of province): Click here to enter text.
Preceptor Signature: ______
Manager Agreement
I agree to support the preceptor above in his/her efforts to provide the student with an optimal learning experience.
Manager’s Name:Click here to enter text. (or Check here if same as preceptor above) Manager’s Signature: ______
University of Toronto, Leslie L. Dan Faculty of Pharmacy, Office of Experiential Education, Tel: 416-978-0280. September 2015