Tab #2 = E*Value Website: To Be Forwarded in May 2009 Tab ... · 2. Preceptor/Site Self-Evaluation Form to be completed annually by the preceptor 7. Preceptor Evaluation of Student

5/1/20094:04 PM01. Table of Contents. Revised 3.07

TABLE OF CONTENTS Tab #1 = Preceptor Information:

1. Contact Information 2. Rotation Schedule 3. Preceptor Information 4. Enrollment Directions for accessing NDSU Library 5. Non-Employee ID form for enrollment into the NDSU Library website 6. Preceptor/Site Quality Assurance

1. Quality assurance documentation to be completed by Experiential Director/Site visitors from the College of Pharmacy.

2. Preceptor/Site Self-Evaluation Form to be completed annually by the preceptor 7. Preceptor Evaluation of Student Form

Tab #2 = E*Value Website: To Be Forwarded in May 2009 Tab #3 = Student Information:

1. Contacts/References 2. Rotation Schedule 3. Policies and Procedures

a. Eligibility Requirements b. Rotation Changes c. Annual Leave Form d. Holidays e. Storm Days f. Evaluation Information g. Grading System

4. ND Board of Pharmacy Affidavit of Licensed Pharmacists/Preceptors 5. ND Board of Pharmacy Progress Report Form 6. Expectations/Objectives for Required APPE rotations

a. Adult Medicine Advanced Pharmacy Experience b. Community Advanced Practice Experience c. Hospital Advanced Practice Experience d. Rural Advanced Pharmacy Experience

i. Rural Housing Information ii. List of Housing Directors for ND State Universities & Colleges

e. Elective Advanced Pharmacy Experiences i. IHS information

f. Student Dress Code

Tab #4 = Personal Portfolio Information 1. Letter from the ND State Board of Pharmacy 2. P4 E*Value Personal Portfolio Requirements 3. Information Regarding the Personal Portfolio 4. Pointers for pharmaceutical care plans 5. Tips From Former P4 Students

5/1/20094:04 PM01. Table of Contents. Revised 3.07

Tab #5 = Forms: 1. Memorandum of Understanding Form 2. Student Site/Preceptor Evaluation 3. Description of the Preceptor of the Year Award 4. Preceptor of the Year Nomination Form 5. Annual Leave Form 6. Rotation Assignment Change Request Form 7. Information Regarding Hepatitis B Vaccine 8. Student Hepatitis B Declination Form (Waiver of Liability) 9. ND Board of Pharmacy Affidavit of Licensed Pharmacists/Preceptors 10. ND Board of Pharmacy Progress Report Form 11. Example of Resume Cover Letter 12. Student Field Trip Assumption of Risk and Release Form 13. Student/Organization Request for Travel Funds Form 14. Preceptor Evaluation of the Student

Tab #6 = Notes/Documents

PRECEPTOR NOTES/CONTACTS

To All Preceptors:

Because we are confirming rotations, sometimes a year in advance, we know that changes can occur. If you will be leaving the practice in which you have agreed to take an APPE student, please contact Paul Connelley or Wanda Roden to make us aware of this change, so that we can more efficiently manage student and site expectations. Please see our contact information below.

It is the responsibility of the student to send a copy of their resume to you two weeks in advance of their rotation. They are also required to telephone you during the week prior to their arrival to learn of the time to meet, proper attire, where to park, and any other information that you would like to share with them prior to the beginning of the rotation.

Wanda Roden, R.Ph (W) 701-231-5178 [email protected]

Paul Connelley (W) 701-231-7722 [email protected]

(F) 701-231-7606

E*Value Website https://www.e-value.net

Mailing Address: Pharmacy Practice NDSU Dept. 2660 118S Sudro Hall, P.O. Box 6050 Fargo, ND 58108-6050

mailto:[email protected]�


https://www.e-value.net/�

5/1/20094:05 PM03. 2009.2010 Rotation Dates.3.20.091

Advanced Pharmacy Practice Experience: 2009/2010

The Pharm.D APPE year will begin on June 22, 2009 at 8:00 am and will end on April 30, 2010 at 5:00 pm. The Experiential Year is comprised of five-week rotations and is further segregated into required and elective rotations. The four required rotations include; adult medicine, community advanced practice, hospital advanced practice, and rural health. The additional four rotations are considered elective rotations.

Rot.#

2009-2010 Five-Week Rotations Schedule NDSU

1 2 3 4 5 6 7 8

Begin 06/22/09 07/27/09 08/31/09 10/05/09 11/09/09 01/19/10 02/22/10 03/29/10

End 07/24/09 08/28/09 10/02/09 11/06/09 12/11/09 02/19/10 03/26/10 04/30/10

NDSU Rot. #

2009-2010 Five-Week Rotations Schedule

N/A

1

2

3

4

5

6

7

8

UofM Rot. #

1

2

3

4

5

6

7

8

9

Begin 5/18/09 06/22/09 07/27/09 08/31/09 10/05/09 11/09/09 01/19/10 02/22/10 03/29/10

End 6/19/09 07/24/09 08/28/09 10/02/09 11/06/09 12/11/09 02/19/10 03/26/10 04/30/10

2009/2010 Holidays

Please note that the Holiday Break is: December 14, 2009 through January 18 , 2010, with January 18

All students are allowed time off during the following official 2009/2010 University holidays: Martin Luther King, Jr. Jan. 18, 2010* Independence Day July 3, 2009 Presidents’ Day Feb. 15, 2010 Labor Day Sept. 7, 2009 Good Friday April 2, 2010 Veteran’s Day Nov. 11, 2009 Easter Monday April 5, 2010 Thanksgiving Day Nov. 26, 2009 Thanksgiving Friday Nov. 27, 2009

th being Martin Luther King, Jr. Day.* The Midyear ASHP meeting is December 4 – 8, 2009. Students interested in attending will need to confirm dates with Experiential Director through email. All students attending this meeting will be required to write a 2 page, double spaced, paper on their experiences at the meeting. This paper will be due within 1 week following the meeting.

G:\Pharmacy\Website\2009-2010 APPE Manual\04. Copy of Preceptor Information.doc5/1/20094:06 PM 1

PRECEPTOR INFORMATION

One person will serve as the primary preceptor at each site. The preceptor may be the Pharmacist-in-Charge, faculty, adjunct faculty, or any other approved Registered Pharmacist practicing full time at that site. The preceptor should meet with the student routinely during each week to review responsibilities and discuss the program. However, the student may be assigned to another pharmacist for a particular period of time. The student has the responsibility of actively seeking information and learning during a rotation. Passive participation or dependence on the preceptor to provide a satisfactory experience is not acceptable. Preceptors have been vocal in their criticism of students who do not "challenge the preceptor", ask questions, or demonstrate curiosity about the operation of the pharmacy and responsibilities, functions, and activities of the pharmacist. It is the prerogative of the pharmacist/preceptor at any experiential site to request the reassignment of a student for any reason. The Director of Experiential Programs will re-assign the student to another site based on availability of cooperating preceptors. If the request is based on problems with the student's cooperation, participation, attitude, or behavior, the student may receive partial credit or no credit for the completed portion of the rotation. This decision will be determined following consultations between the Dean of the College, the Director of Experiential Programs, the preceptor, and the student.

MONITORING Evaluation of the Advanced Pharmacy Experience will be conducted in the same manner as all other courses offered by the College of Pharmacy. Students will be required to complete written forms evaluating the site, the preceptor and the program during their five week experience. These forms will be completed following the five week experience. Students are informed to immediately notify the Director of Experiential Programs of any issues surrounding their preceptor or rotation. The Director, or the College, will then follow up with preceptors and students on any identified problem areas. Preceptors are required to complete one written evaluation form at the end of each rotation. An oral mid-term evaluation is recommended to ensure that the student is meeting the objectives and expectations of the rotation. Preceptors are asked to immediately notify the Director (701-231-5178) of any problems with their students or the rotation.

EDUCATIONAL RESPONSIBILITIES OF THE PRECEPTOR The integration of classroom knowledge into professional performance is recognized as an essential activity in the achievement of professionalism. The following list emphasizes the serious responsibilities inherent in accepting the role of a preceptor:

a. Understand the dimensions, responsibilities and tasks of pharmacy practice and identify those tasks which are performed in the preceptor's pharmacy.

b. Assess the student's knowledge and experience base before assigning learning

experiences. From both the educational and public safety standpoints, the student's duties should not exceed his/her educational level.


c. Review the assessment of the student's entry level knowledge and experience with the student, pointing out strengths and weaknesses and assigning learning experiences to correct deficiencies.

d. Set clear learning objectives for the student, based on the student's education and

experience and upon the dimensions, responsibilities and tasks of pharmacy practice. Plan specific learning activities that will contribute to the mastery of each task and ensure time to practice the skill in the pharmacy. Thoroughly review such topics as patient confidentiality, security practices, professional demeanor, patient communication, communication with other health professionals, work schedules, lines of responsibility, relationships with the preceptor and other staff members, employee benefits, professional supervision, and the performance evaluation.

f. Provide information and demonstrate appropriate practice performance.

g. Serve as a learning resource and role model for the student while infusing new values and

attitudes.

h. Provide a broad scope of educational experiences. Special projects may be arranged, such as in-service training, design of record systems, and newsletter writing. Exchange visits to other pharmacies may provide exposure to alternative distribution, recordkeeping and control systems.

i. Systematically rotate the student's responsibilities to provide a wide variety of

experiences.

j. Coordinate and share teaching and supervisory responsibilities with other pharmacists.

k. Close and continuous supervision of the student's performance, appropriate for his/her educational level and experience, is required by all preceptors. However, the advanced student's learning is facilitated when some latitude in independent performance is permitted. Intermittent checks of performance and retrospective reviews may be appropriate for the advanced student who has acquired the judgment making ability required for practice.

l. Provide positive corrective feedback during the learning process. Discuss questions,

criticisms or disagreements in private.

m. Evaluate and document the student's abilities during and at the completion of the Advanced Pharmacy Experience. These evaluations may take the form of exit interviews, performance rating scales, review of student reports, and performance tests.

n. Meet with representatives of the Board of Pharmacy or of the College of Pharmacy who

are responsible for coordinating the Advanced Pharmacy Practice Experience Program.

o. Encourage/model active participation in continuing education and lifelong learning.


THE LEARNING SEQUENCE Explanation, demonstration, and performance provide the best learning pattern for most competencies. Repetitive performance should assure mastery. Some competencies do not permit demonstration as they are knowledge based rather than performance based. Some performance based competencies do not permit frequent repetition as they are not encountered that often in the operation of the pharmacy. Sufficient explanation of the mechanics of completing a task can be given by the preceptor to assure the student understands and could perform the task if required. Several kinds of student learning experiences occur throughout the year of experiential rotations. New Knowledge (e.g., "it is our policy to purchase from the following distributor for the

following reasons.”) New Skills (e.g., "In order to tactfully explain to Mrs. Smith the contraindication

between her prescription and her aspirin-containing over-the-counter product, try this approach ...")

New Values/Attitudes (e.g., "Don't you agree that it's more important to spend time with the patient than ...") Creative Ideas (e.g., "That's a good suggestion. Why don't you put together your thoughts

on the work flow/redesign to promote increased efficiency and productivity in the pharmacy.")

These experiences generate greater student impact given the preceptor engages the student in The Learning Sequence process.

The Learning Sequence

The student learns by: The preceptor teaches by:

Listening Telling * Reading

Observing Demonstrating

PerformingSupervising Evaluating Reinforcing

**

* Provision for questioning and feedback is always provided **

As previously stated, mastery of most responsibilities and tasks will be achieved and demonstrated after

Achieving mastery of the task by practice Instead of making assumptions about the student’s prior experience and competencies, the model suggests the importance of "checking out" the student through prior basic instructions followed with several demonstrations. Then the student advances as the preceptor deems acceptable based on the student's understanding, cooperation, and willingness to perform new tasks. The model does not suggest that instructions and demonstrations are to be repeated continuously. The student should move through the learning sequence toward mastery of professional tasks.


repetitive performance. When tasks are performed infrequently, discussion may be the only teaching opportunity.

KEY STEPS IN LEARNING

The learning activities suggested for students can be summarized in five steps.

Set Clear Learning Objectives

Determine the Achievement Level and Learning Needs of the Student

Plan Specific Learning Activities

Implement the Learning Plan

Evaluate and Feedback the Results

1. Set Clear Learning Objectives

Preceptors are responsible for supervising the learning of students who will practice in general practice locations and in various roles. The preceptor and the student should begin each rotation with a prepared set of learning objectives that represent a description of the knowledge, skills, and capabilities required to practice pharmacy in that setting. It is important that the student be exposed to the different roles and tasks. This may require arrangement of learning experiences outside of the preceptor's pharmacy.

2. Determine the Achievement Level and Learning Needs of the Student Specifically ask the student what he/she knows, what they have experienced, and their

expectations during the rotation you are supervising. Decide what knowledge, skills, and attitudes are deficient in the student's background and focus the learning on these deficiencies.

3. Plan Specific Learning Activities

Decide on the experiences/learning activities that will be necessary to meet the learning objectives of both the student and the preceptor. Learning activities may include daily practice responsibilities, observation of selected tasks, working on assignments and special projects, reading journal articles or other references, attending meetings and seminars, discussions with the preceptor and other pharmacists, and evaluation of performance.

4. Implement the Learning Plan

Develop a schedule of experiences/learning activities that are possible within your rotation site and during the rotation time frame. Arrange for special visits to other practice sites or with other health professionals. Determine the best time best for the preceptor to meet with the student to offer advice and feedback.

5. Evaluate and Feedback the Results

If possible, it is important to provide feedback when the behavior is observed. Provide corrective and supportive feedback as often as possible focusing on specific assignments or tasks performed.


THE IMPORTANCE OF FEEDBACK

The student needs to know whether he/she is performing appropriately. Approval by the preceptor and appreciation from patients and other health professionals are factors which will encourage the student to repeat proper performance. An awareness of satisfactory performance is as important as an awareness of deficiencies because a student needs to understand how to improve on a particular skill so that he/she can increase proficiency through practice in a future rotation. Reinforcement of the student's learning/performance will be reinforced by the student's feelings about the learning process and his/her performance. In addition to positive reinforcement from the preceptor for good performance, the preceptor should discuss/quiz the student regularly on assigned tasks. Correct responses contribute to positive reinforcement. Incorrect answers are not necessarily a sign of failure, but a signal to re-emphasize a particular task. Suggested Questions to initiate conversation and begin feedback for the Mid-rotation and/or Final Rotation Evaluations

1. How would you rate your performance so far? How do you think your care plans are going? 2. What do you think of your ……….? …. patient counseling? …. case presentation delivery? …. grand rounds? …. morning reports? …. time management skills? 3. Why do you think that? Explain what you feel you are doing good… or not so well? 4. How could you improve? 5. What would you like to improve in the coming weeks? 6. Set specific objectives for the student or incorporate in objective setting along with the student. 7. Do you have enough time to work on projects/tasks here? Too much time? 8. What is your favorite activity for this rotation…of the day? 9. What is your least favorite activity? Why? 10. What is the most important task you are assigned? 11. What did you find helpful in learning/preparing for this rotation? 12. What would you like to see change in the future? 13. What would you say are the strengths and weaknesses of this rotation?

14. What skills have you learned that you plan to use in the future

Portions of this manual have been extracted from the AACP/NABP manual, The Internship Experience, the Drake University Competency Statements developed with the support of SmithKline Corporation and the Community Practice Externship Manual of the University Of Minnesota College Of Pharmacy.


ADDITIONAL STUDENT “Learning Activities” WHILE ON ROTATIONS There are certain “downtimes” when the student has completed the daily/weekly tasks and is looking for something else to do…..or when you, the preceptor, need some time to complete your own work. The following is a list of suggested activities: (P4 students will also receive this listing and a discussion of how to accomplish each for their benefit.) Not all ideas listed will work for all sites. Feel free to adapt each as needed. Hold the student responsible for an in-service to an audience such as nurses, pharmacy tech, nursing home staff or residents, service clubs (Rotary, Kiwanis), homemakers groups, support groups, churches, etc. Following proper instruction, have the student conduct follow up calls regarding mailed out RXs, new antibiotic RXs, and any new RX. Observe and encourage the student to be involved in all aspects of counseling on RX and OTC items. Have the student research political awareness items and attend local district/community meetings. Have the student participate in DUR projects in retail, community, and/or hospital sites, when appropriate. Have the student prepare and deliver a presentation on a class of drugs that the student is least familiar/comfortable with. Establish a core-reading list of journals. Have scheduled discussions about relevant topics or contents of current listings. Keep a list of questions to challenge the student’s use of references Establish a journal club within a retail, community, or hospital setting, with follow up discussions when appropriate. Have the student participate in high school career days or other such events. Provide “brown bag” opportunities within the community. Have the student complete a community service, or other event. Write and/or participate in a TV/radio commercial. Have the students develop some “in-house” patient education. Topics can be specific to certain medications such as Coumadin, disease states, or topics of interest such as the side effects of cholesterol lowering agents. Upon completion of a project, have the student complete an assessment of the effectiveness of the project and revise if improvement is needed. Have the student participate in nursing home reviews. Use the special talents of students for special projects through the solicitation of the student’s own ideas as to what they would like to work on. Have the students participate in a renal dosing project. Have the student prepare a discussion on “professionalism in pharmacy.” Ask them to relate situations where they can explain to you what is appropriate, and what is not appropriate. Keep a list of “drug information” questions that you have been asked to research. Compile this listing and give to the student, asking them to note their references. Discuss selected medications/issues.

Enrollment Directions for the NDSU Library

Please complete the “NDSU Non-Employee ID Data Form” that is on the next page and fax it to 701-231-8541. Once the form is processed through the ITS department, Paul Connelley will notify you of your personal “Emplid number”. Once you have this number, please follow the directions listed below for access to the NDSU library website. If you have any questions, please contact Paul Connelley at 701-231-7722 or [email protected]. This document describes how you may obtain services from North Dakota State University that enable you to sign-on to the NDSU Library. 1. Go to http://enroll.nodak.edu using a Web browser. 2. Click “Continue.”

3. Find the option “If you do not know your Electronic ID and password”,

check this box and click “Continue”

4. Enter “Last Name” and “Emplid” If you see the message, “We don’t know who you are,” contact the NDSU Help Desk for assistance:

Phone: 231-8685, Option 1 E-mail: [email protected]

5. Enter the Password, by default, the password is XxxYYZZZZ (where “Xxx”

= first three letter of the month you were born, first letter is capitalized, “YY” = middle two numbers of your Social Security Number, “ZZZZ” = all four digits of the year that you were born)

a. If this password does not work call the ITS Help Desk 701-231-

8685 Option 1

6. The next screen will say that you need to take the NDSU acceptable use policy quiz, click “Continue”

7. Answer the next 14 questions (the quiz acts as training, so you cannot

fail).

8. After answering the questions, you will be prompted to change your password. Enter the password from above, then enter a new password (8 or more characters, upper and lower case letters, numbers or symbols). Passwords must have at least 3 different kinds of characters

http://enroll.nodak.edu/�

(1 upper/lower case letter, 1 number and/or 1 symbol). Password Example: Hjan123$.

PLEASE NOTE ELECTRONIC ID (EID).

9. You will then be prompted to either create an NDSU E-Mail address or

setup a mail forward (mail addressed to [email protected] will be delivered to the e-mail address of your choice). You have to choose one of these two choices to complete the enrollment.

a. Choose to have your mail forwarded by clicking that box and enter

the e-mail address you would like to have your mail forwarded to and click “Change your maildrop.” You must have a personal e-mail address to use the NDSU Library. NDSU will use this email account to communicate with you.

PLEASE NOTE: NDSU removes accounts several times each year. You may receive notice via email that your account is scheduled for removal at some time in the future. Please follow the instructions in such an email to ensure that your account is left in tack so that you can continue to access and use the NDSU Library.

10. The enroll process has been completed, you can now close your browser and enjoy the rest of your day. Your services will be activated the next business day.

11. The next business day, go to http//www.ndsu.edu

using your web browser. Click on the Library link and sign-on using your Electronic ID (EID) and the password that you created in step 8 above. Your EID has a “firstname.lastname” format.

NDSU Non-Employee ID Data Form NDSU Information Technology Systems Application

Edit Data: 11/08/05 tys

IMPORTANT: This form is used to process preceptor information allowing the NDSU ITS department to grant preceptors access to NDSU websites. Please supply the following information for the North Dakota State University Records. Please type or print legibly. Prefix: ____ Dr. ____ Mr. ____ Mrs. ____ Ms. ____Miss Name: _______________________________________________________________________________________ First Middle Last Date of Birth____________________________ Social Security Number___________________________________ (00/00/0000) (000-00-0000) Suffix: ____Sr. ____ Jr. ____ first ____ second ____ third ____ fourth Site Name:___________________________________________________ Site (Business) Address: ___________________________________________________________________________ Street City County State Zip+4 Site (Business) Phone Number: ______________________ (000) 000-0000 Preceptor’s E-mail address: __________________________________________________________ I require an EMPLID for: __X___ Associate Non-employed Faculty/Staff _________________________________________________ _________________________________ Preceptor’s Signature Current Date Please return this form to: Theresa Semmens IACC Room 206 PO Box 5164 Fargo, ND 58105-5164 E-mail: [email protected] Business Phone: 701.231.5870 Fax: 701.231.8541 NOTE: FAX as good as original signature If you were a student at NDSU and have changed your name since, please call the Registra’ office at 701-231-7981 to request a name change to your account. If you do not provide your SSN, we will be unable to assign you an account. If you are concerned about sharing your SSN with us, please call Theresa Semmens, at 701.231.5870.

For ITS use only: Approved: ____Yes ____ No EmplID # _________________ Date Assigned: _____________

5/1/20094:07 PM07. Professional Experience Site-Preceptor Quality Assurance

Professional Experience Site and Preceptor Quality Assurance

Provision of quality professional experiential education to student pharmacists requires ongoing oversight regarding the quality of preceptors for these experiences and the practice settings in which they practice. Standard No. 14. Curricular Core: Pharmacy Practice Experiences, of the ACPE Draft Revised Doctor of Pharmacy Standards and Guidelines proposes minimum components of this quality assurance process. Preceptors practice in a wide variety of practice settings, provide these experiences to varying numbers of students and different educational institutions, and have a range of relationships with colleges/schools of pharmacy. A general quality assurance process compliant with current ACPE Standards, yet applicable to the diverse nature of the professional experience environment is proposed. Additionally, since many sites provide experiential education for students from a number of educational institutions, a common methodology used by regional institutions will minimize duplication of effort in completing the quality assurance requirements for all programs.

• orientation to the educational institutions mission and goals as it applies to experiential education

Initiation of New Experience Site The Director of Experiential Education or their designate will evaluate all new sites before being approved for experiential education. Whenever possible this will be done in person at the practice site after review of submitted materials. In cases where the site is not within driving distance, or for other reasons it is impractical to do in person, the Director or their designate will evaluate the site and the preceptor via telephone conversations after review of submitted materials. Evaluation will be completed in the same manner for all practice sites wishing to provide experiential education. Established criteria (see the attached Experiential Site and Preceptor Evaluation form) will be used to complete the process. This information will supplement the demographic and descriptive information the Experiential Office maintains on all practice sites and preceptors. The individual school/college will determine the specific site and preceptor demographic and descriptive information that is obtained. If a new experience site and preceptors are concurrently approved by another institution in the Region for the delivery of experiential education, that approval may be deemed as acceptable in meeting this requirement. Specific expectations of this institution would still need to be discussed with the site. Recommended topics to be discussed in the approval process include but are not limited to the following:

• applicability of an available syllabus, or development of a site specific syllabus for the experience (experience goals, learning objectives, student activities, assessment and grading criteria)

• defined expectations of the site and preceptor in the education of the student pharmacist o curriculum requirements and integration o experience goals and objectives o assessment and feedback expectations of preceptors, students and the educational

institution • discussion of the expected types and volume of patients in the practice setting • defined roles and responsibilities of the student pharmacist in the practice setting • discussion of student supervision in the practice setting • guidance on setting expectations with students, assessment strategies, provision of feedback and

grading methodologies.

An abbreviated version of the process will be used if it is anticipated the site will be used on a limited basis. Following the site visit, the Director will send the preceptor a letter that summarizes their discussions during the visit. If it is approved as a new site, a Site Agreement will be sent to the site for appropriate administrative signatures.


Current Sites The Director or their designate will evaluate all routinely used experience sites in person at least once every two years. Sites taking less than five students per year, and those not within driving distance may be evaluated via telephone conversations. Sites may be evaluated more frequently if needed (e.g., poor student evaluations, change in preceptor at the site). This biennial evaluation is to determine continued approval for completion of student pharmacist experiential education at the practice site. The Director of Experiential Education or their designate will evaluate the site and preceptor according to established criteria (see the attached Experiential Site and Preceptor Evaluation form). During the site visit, the preceptor’s completed self-evaluation (see attached form) in addition to student evaluations of the site and preceptor will be discussed. Roles and responsibilities of both the preceptor and the institution will be reviewed. The preceptor will be commended for areas in which the preceptor and/or site are meeting or exceeding expectations. Constructive feedback that addresses specific areas that need improvement will also be discussed with the preceptor. Working with the Director or their designate, the preceptor will develop an improvement plan, if necessary. Preceptor feedback regarding the School’s experiential program will be solicited during the evaluation discussion. Following the site visit, the Director will send the preceptor a letter that summarizes their discussions during the visit. A copy of the experiential site and preceptor evaluation form, student evaluations, the preceptor’s self-evaluation, and the letter will be placed in the site’s file at the school. Experiential sites not granted approval, or those granted conditional approval and not meeting those conditions will not be used as a training site for the program. Ongoing Communication with Experience Sites and Preceptors Preceptors at experiential sites will be routinely provided with summative data from student pharmacist completed evaluations of the site and preceptors. Preceptors at the site will routinely complete self-evaluation of their site, and their performance as preceptors and provide this to the Director of Experiential Education. This exchange of information should occur at least annually, and allow for ongoing quality improvement at the site. Professional Experience Program Advisory (PEP) Committee: The Professional Experience Program Advisory (PEP) committee will provide oversight of the QA process for the experiential program.


Quality Assurance Documentation Experiential Site and Preceptor Evaluation

Name of Site: Type of Rotation: Preceptor/Contact Person: Title: Address: Phone Number: E-Mail: Site Information Comments Adequate patient volume and breadth for student learning

Y N NA

The student has access to patient information Y N NA The student has the opportunity to interact with other health professionals as is pertinent to the specific experience

Y N NA

The student has access to a computer with Internet capabilities

Y N NA

The student has access to appropriate drug and medical information resources

Y N

Adequate space for student involvement with pharmacy activities and interaction with pharmacists, other health professionals and patients

Y N

The site displays a professional image Y N The site administration support student involvement at the site

Y N

The staff (i.e., pharmacists and technicians) support student interactions and involvement

Y N

Pharmaceutical care philosophy evident in practice activities

Y N

Activities, projects and assignments will fulfill learning objectives of the learning experience

Y N

Amount and quality of time with the student is appropriate

Y N NA

Appropriate role-modeling by pharmacists is available to the student pharmacist

Y N

The student is evaluated by direct observation when appropriate (e.g., dispensing skills)

Y N NA

Regular and consistent feedback is given to the student

Y N NA

A written or verbal evaluation is discussed with the student at the middle of the rotation

Y N NA

A written evaluation is discussed with the student at the end of the rotation

Y N NA

Student expectations and responsibilities are clear and are expressed to the student at the beginning of the experience

Y N NA

Has served as an experience site for student pharmacists previously? If yes, when and how many:

Y N NA


What schools/colleges of pharmacy send students to the site on a regular basis?

Rotation Preceptors at the Site

Student Pharmacist Activities: (check all that apply) Prepare, dispense, and distribute medications. Provide pharmacotherapy management as part of a multidisciplinary patient-care team. Routinely assess patients and drug therapy to formulate drug therapy recommendations. Implement pharmacotherapy or drug policy plans. Monitor and modify pharmacotherapeutic or drug policy plans. Educate patients, students, and other health care professionals about the purpose and safe, effective, and

economic use of medications. Prepare and disseminate written drug information (e.g., consultations, drug monographs, newsletters, etc.). Provide expertise to or serve on patient-care committees (e.g., Pharmacy and Therapeutics, Infection Control,

etc.).

Activities, projects, and assignments that are required of the student: Comments: Follow-up Required No Yes, in months Site Approved for Period to Experiential Director Date:

5/1/20094:07 PM08. Professional Experience Program Preceptor Self-Evaluation Form

Professional Experience Program Preceptor Self-Evaluation

Form

Date:

Preceptor:

Site:

Use the following scale to indicate your agreement with the following statements as they pertain to you and your practice site: 6 = Strongly Agree 3 = Slightly Disagree 5 = Agree 2 = Disagree 4 = Slightly Agree 1 = Strongly Disagree NA = Not applicable to the Rotation or Site You are willing to continue serving as a preceptor for this rotation. 6 5 4 3 2 1 NA You relate to the students as an individual. 6 5 4 3 2 1 NA You encourage students to actively participate in discussions and problem-solving exercises.

6 5 4 3 2 1 NA

You provide the students with adequate patient contact on this rotation to meet the learning objectives.

6 5 4 3 2 1 NA

You provide the students access to necessary patient information. 6 5 4 3 2 1 NA Students are encouraged to access and use resource materials. 6 5 4 3 2 1 NA You provide students with access to all necessary reference materials, either hard copy or via electronic means.

6 5 4 3 2 1 NA

You described your approach to thinking about therapeutic problems. 6 5 4 3 2 1 NA You were readily available to answer questions and concerns. 6 5 4 3 2 1 NA You provided good direction and feedback. 6 5 4 3 2 1 NA You were knowledgeable in your response to questions or your approach to therapy.

6 5 4 3 2 1 NA

You evaluated the students after two weeks on the rotation. 6 5 4 3 2 1 NA You evaluated the students at the end of the rotation in a manner that was helpful to the student.

6 5 4 3 2 1 NA

You served as a role model for a pharmacist practicing in this practice setting.

6 5 4 3 2 1 NA

The rotation provided students opportunities to interact with other health care professionals.

6 5 4 3 2 1 NA

The goals and objectives of the rotation were outlined and/or explained at the beginning of the rotation.

6 5 4 3 2 1 NA

Rotation activities were well organized and structured. 6 5 4 3 2 1 NA This rotation provided an environment (physical and philosophical) that facilitated student learning.

6 5 4 3 2 1 NA

Others at the rotation site were receptive and willing to interact with the students.

6 5 4 3 2 1 NA

The students’ verbal communication skills were enhanced during this rotation.

6 5 4 3 2 1 NA

The students’ written communication skills or documentation skills were enhanced during this rotation.

6 5 4 3 2 1 NA

The students’ clinical skills were enhanced on this rotation. 6 5 4 3 2 1 NA The students were able to apply previously learned materials on this rotation.

6 5 4 3 2 1 NA

This experience will help students become better pharmacists. 6 5 4 3 2 1 NA

5/1/20094:07 PM08. Professional Experience Program Preceptor Self-Evaluation Form

Overall, how would you rate your practice experience? Excellent Good Fair Poor Please elaborate and give examples. How might your practice experience be improved?

5/1/20094:09 PM09. IPPE.APPE Preceptor Evaluation. 3.20.09 1

Student Evaluation by Preceptor North Dakota State University Department of Pharmacy

Excellent Average Poor NAStudent Name: Student demonstrated Student demonstrated Student needs DoesPreceptor: excellent skills in this satisfactory skills in improvement in NotRotation Site: area; was extremely area; was generally this area; was ApplyRotation #: effective and/or very effective and/or somewhatMid Evaluation Date (Recommended but not mandatory): consistent.(Could serve consistent. (Appropriate ineffective and/orFinal Evaluation Date: as a role model) for this level.) inconsistent.Section A: Ability Based Outcomes1. Attitudes and Values/ProfessionalismStudent arrives at practice site and meetings on time, meets deadlines for completion of tasks and responsibilities.Student seeks knowledge, asks questions, searches for information, and takes responsibility for his/her ownlearning.Student responds openly and positively to constructive feedback and modifies behavior if necessary.Student demonstrates regard for patients, superiors, colleagues, other personnel, and property.Student demonstrates empathy for patients.Student makes decisions and performs duties in accordance with legal, ethical, social, cultural, economic, andprofessional guidelines.Student adheres to dress code and maintains personal health and good grooming habits as put forth by thepractice setting.

2. Communication SkillsStudent is able to communicate in a caring and respectful manner in all situations using appropriate listening,verbal, nonverbal, and written skills.Student actively and appropriately engages in dialogue or discussion. Not afraid to express his/her viewpoint.Student clearly communicates thoughts, and uses appropriate vocabulary, gestures and mannerisms toconvey information.Student acts and communicates in a self-assured manner, yet with modesty and humility.Identifies and collects all information needed to respond to an information request from anotherhealth care professional using appropriate resources and technology.Responds to an information request from a patient.

3. Scientific FoundationMakes decisions regarding complex problems that require the integration of scientific, social, cultural, and ethical issues with one's ideas and values.Recommends medication doses and dosage schedules for a specific patient based uponrelevant patient factors and drug pharmacodynamic and pharmacokinetic properties.

4. Patient Centered CareStudent establishes relationships with patients, care givers, and other health care professionals asnecessary to provide pharmaceutical care.Evaluates information obtained from the patient's history and physical assessment.Student effectively counsels, communicates, refers and selects the appropriate medications or care plansfor patients.


Patient Centered Care (cont.) Excellent Average Poor NARecommends appropriate drug therapy for a specific patient.Documents information related to the identification, resolution, or prevention of drug-relatedproblems in individual patients.Student effectively retrieves and evaluates medical literature and is able to analyze and apply information indecision making.5. Systems ManagementAccurately select, prepare, and dispense medicaitons in a manner that promotes safe and effective use.Accurately prepare/compound individual or bulk medication in a manner that promotes safe and effective use.Prepare, store, and assure quality of sterile dosage forms.Provide counseling to patients, families, and caregivers.Apply patient and population-specific data, quality assurance strategies, and research processes to optimizepatient outcomes.Section B: Special ProjectsActivity 1: Public Health ProjectCompleted activity was appropriate for the intended audience.Activity and supporting materials were of a professional quality.Demonstrated the ability to follow through with the activity from conception to conclusion.Activity 2:Completed activity was appropriate for the intended audience.Activity and supporting materials were of a professional quality.Demonstrate the ability to follow through with the activity from conception to conclusion.Activity 3: Completed activity was appropriate for the intended audience.Activity and supporting materials were of a professional quality.Demonstrate the ability to follow through with the activity from conception to conclusion.Section C: CommentsComments:

Identify one area in which the student excelled:

Identify one area in which the student could further develop his/her skills:

Signature certifies student completed 200 rotation hours _____________________________________________________Preceptor Signature Date

E*Value Instructions To Be Emailed to Preceptors in May 2009

CONTACTS/REFERENCES

Rotation Preceptor Phone Number Email address #1

#2

#3

#4

#5

#6

#7

#8

*Please note that preceptors may change throughout the year. Therefore it is necessary for you to continually check E*Value to confirm preceptor status. *Because many of you go outside of Fargo for Rotation # 7, we recommend that you contact/telephone your Rotation # 7 preceptor in December, prior to Christmas, verifying your Rotation # 7 dates. Please speak directly with the preceptor listed on E*Value. If, for some reason, this preceptor has changed or the site does not know of your rotation, please contact us immediately. We then have time to respond and work through the situation. Please keep in mind that we are arranging these rotations almost a year in advance of your actual arrival and many things can change in a year.

Important Phone #’s & Emails:

Wanda Roden, R.Ph. (W) 701-231-5178 [email protected] Paul Connelley (W) 701-231-7722 [email protected]

(F) 701-231-7606

Liz Frannea (W) 701-231-7601 [email protected] ND State Board (W) 701-328-9535 http://www.nodakpharmacy.com/ (F) 701-258-9312 http://www.nabp.net/

MN State Board (W) 651-201-2825 http://www.phcybrd.state.mn.us/ (F) 651-201-2837 E*Value website https://www.e-value.net



http://www.nodakpharmacy.com/�

http://www.nabp.net/�

http://www.phcybrd.state.mn.us/�

https://www.e-value.net/�

5/1/20094:11 PM12. 2009.2010 Rotation Dates.3.20.091

Advanced Pharmacy Practice Experience: 2009/2010

The Pharm.D APPE year will begin on June 22, 2009 at 8:00 am and will end on April 30, 2010 at 5:00 pm. The Experiential Year is comprised of five-week rotations and is further segregated into required and elective rotations. The four required rotations include; adult medicine, community advanced practice, hospital advanced practice, and rural health. The additional four rotations are considered elective rotations.

Rot.#

2009-2010 Five-Week Rotations Schedule NDSU

1 2 3 4 5 6 7 8

Begin 06/22/09 07/27/09 08/31/09 10/05/09 11/09/09 01/19/10 02/22/10 03/29/10

End 07/24/09 08/28/09 10/02/09 11/06/09 12/11/09 02/19/10 03/26/10 04/30/10

NDSU Rot. #

2009-2010 Five-Week Rotations Schedule

N/A

1

2

3

4

5

6

7

8

UofM Rot. #

1

2

3

4

5

6

7

8

9

Begin 5/18/09 06/22/09 07/27/09 08/31/09 10/05/09 11/09/09 01/19/10 02/22/10 03/29/10

End 6/19/09 07/24/09 08/28/09 10/02/09 11/06/09 12/11/09 02/19/10 03/26/10 04/30/10

2009/2010 Holidays

Please note that the Holiday Break is: December 14, 2009 through January 18 , 2010, with January 18

All students are allowed time off during the following official 2009/2010 University holidays: Martin Luther King, Jr. Jan. 18, 2010* Independence Day July 3, 2009 Presidents’ Day Feb. 15, 2010 Labor Day Sept. 7, 2009 Good Friday April 2, 2010 Veteran’s Day Nov. 11, 2009 Easter Monday April 5, 2010 Thanksgiving Day Nov. 26, 2009 Thanksgiving Friday Nov. 27, 2009

th being Martin Luther King, Jr. Day.* The Midyear ASHP meeting is December 4 – 8, 2009. Students interested in attending will need to confirm dates with Experiential Director through email. All students attending this meeting will be required to write a 2 page, double spaced, paper on their experiences at the meeting. This paper will be due within 1 week following the meeting.

5/1/20094:11 PM13. Policies and Procedures.9.12.08

Policies & Procedures

Advanced Pharmacy Practice Experience (APPE) North Dakota State University

Department of Pharmacy Practice

1. The student will comply with all regulations and practices specified by the pharmacy/institution. 2. Students are required to carry at least minimal limits of professional liability insurance and

health/medical insurance coverage. Copies of this information will be kept in the Office of Experiential Programs and in the E*Value individual student profile.

3. A criminal background check will be completed prior to the start of rotations. Records will be kept on each student in the Experiential Programs office.

4. Students must be registered interns in North Dakota as well as in any state(s) in which they practice. Students are required to provide a copy of the intern license from the individual state/s where they will be completing rotations. Copies will be kept in the Office of Experiential Programs and in the E*Value individual student profile.

5. Students must receive active immunization against Hepatitis B. If this immunization cannot be completed, the student must sign and submit a "Waiver of Liability", which will be kept in the Office of Experiential Programs and in the E*Value individual student profile. Documentation of a annual 2-Step PPD test is also required prior to rotations.

6. Students will consider all information and activities relating to a pharmacy and patients as confidential and under no circumstances, will knowledge so acquired be disclosed to unauthorized persons. Failure to comply with the rule will result in automatic dismissal from the program

7. Students will be expected to be engaged in purposeful, learning activities for a minimum of 40 hours per week.

8. Students will be limited to three 5-week rotations outside of the states of ND, SD, MT, and MN. Exceptions to this policy may be considered and approved by the Experiential Education Committee.

9. Students will not be assigned any APPE rotation in which the student has previously worked for a salary.

10. Students will not request or accept pay or remuneration. With the prior approval of the Experiential Program Director, students may accept reimbursement for room, and/or board and/or commuting expense.

11. Students are limited to no more than one 5-week APPE for which the College provides a stipend. 12. Students may complete no more than two “like” rotations, i.e. no more than 2 elective psychiatry

rotations or no more than 2 Community APPE rotations. Exceptions may be granted to an individual student by the Director of Experiential Programs.

13. During the APPE, a maximum of 3 credits of elective coursework may be taken provided the course(s) are in the evening or otherwise pose no conflict.

14. Students may accept jobs not related to rotation experiences provided that such employment does not interfere with their APPE.

15. Prior to the start of their next rotation, students are required to forward a copy of their resume and a cover letter to the preceptor by the Wednesday of the second to the last week of the prior rotation. On Wednesday, the week prior to the beginning of the rotation, the student is telephone the preceptor to inquire as to where to report, what time to report, where to park, proper attire, etc.

16. Students will present a neat, professional appearance at all times. Dress will be in conformation with the regulations of the institution/pharmacy. While on duty students will display their name badge provided by the College.

17. The student shall be punctual, perform all assigned tasks willingly and cheerfully, and maintain a friendly and professional relationship with employer(s), patients, and other health care providers.


18. Personal phone calls should be scheduled during break times. Avoid making or receiving personal

telephone calls, especially in the prescription work designated area. 19. Students are responsible for the completion of the APPE evaluation forms. These forms are required for

the processing of the semester grade. Evaluation forms may be submitted via the E*Value website, email, regular mail, or fax (701-231-7606) within 2 weeks of the completion of a rotation.

20. The Annual Leave Form will be utilized for all time off (sick, personal, professional). A student is allowed 5 personal days during the 40 weeks, with no more than 2 days occurring during a 5 week rotation

21. Three “professional days” will be allowed in December, for any student wishing to attend the Midyear ASHP conference to become familiar with residency programs across the country. Students must inform the Experiential Director that they will be attending the conference. Following the conference each student will submit a two page essay on their experiences and their residencies of interest.

. Please see more detailed instructions under “Annual Leave Form” further down in the text.

22. During any APPE, if a student puts patients, preceptors or the practice at risk, that student may be immediately dismissed from the rotation and given a failing grade for that rotation.

23. Upon failure of one or more rotations in the experiential year, a student will be required to successfully complete one similar remediation rotation, for each failed rotation. Each plan will be based on the student’s needs and stipulate a time line based on plan criteria. Each remediation rotation must be successfully completed before graduation. If the student does not successfully complete the remediation plan, College policy 3.03, Right to Terminate Enrollment, will be considered. Upon completion of the remediation rotation, the student will be required to make up any rotation that was missed, due to the remediated rotation.

24. If a student is unsuccessful in completing the requirements of any three Advanced Pharmacy Practice Experience rotations, the student shall be permanently dismissed from the College of Pharmacy.

25. The College of Pharmacy retains the right to remove a student from an APPE site and reassign the student if, in the opinion of the Experiential Program Director, and through consultation with the Dean or Pharmacy Practice Department Chair, an incompatibility exists between the student and the preceptor or other personnel.

26. The Experiential Education Committee has final authorization regarding the student’s rotational selections and evaluation of new rotation sites. All recommendations for new sites will be forwarded to the Department of Pharmacy Practice for final approval.

27. Students must fill out a “Study Abroad Form” for International Rotations.

Eligibility Requirements To be eligible for APPE registration, all students must have completed all Pharm D. third year coursework, earning a grade of "C" or better. Students must also hold licensure either as a registered pharmacist or registered intern in the state of North Dakota, as well as in any state where all or any part of the APPE will be completed. All students completing APPE rotations will be required to register for PHARM 581 (Summer semester), 582 (Fall semester), and 583 (Spring semester). Please note that Summer semester will require students to register for 10 credit hours, Fall semester will require the students to register for 15 credit hours, and Spring semester will require the student to register for 15 credit hours.

If a student wishes to make a change in the established schedule, the student must submit a completed “

Rotation Changes

Schedule Change Request”. This form requires the approval and signature of both preceptors involved in the


change. A copy of the completed form must be sent to the Experiential Program Director. Annual Leave Form The “Annual Leave Form” will be utilized for ALL time off related to sickness, professional and personal absences from the rotation site. “Personal Time” is considered time off for sickness, residency/job interviews, and vacation. “Professional Time” is considered time off for events surrounding the College of Pharmacy such as; didactic days, career fair, conventions (maximum of two days allowed), professional conferences designated for attendance by the College of Pharmacy, and legislative day. A student is allowed 5 “personal days” during the 45 weeks, with no more than 2 days occurring during a 5 week rotation. Preceptors have discretion to approve or deny requests for personal leave. The “Annual Leave Form” requires the signature of the preceptor and notification to the college, prior to the actual “leave”. Three “professional days” will be allowed in December, for any student wishing to attend the Midyear ASHP conference to become familiar with residency programs across the country. Students must inform the Experiential Director that they will be attending the conference. Following the conference each student will submit a two page essay on their experiences and their residencies of interest. Holidays All students are allowed time off during official University holidays. Spring break is not considered time off for APPE rotations. New Year’s Day Independence Day Martin Luther King, Jr., Day Labor Day Presidents’ Day Veteran’s Day Good Friday Thanksgiving Day Easter Monday Thanksgiving Friday Memorial Day Christmas Day Storm Days In the Fargo-Moorhead area, students are not expected to report to APPE sites if classes at the University have been cancelled due to inclement weather conditions. Students located outside the F-M area shall follow the local public school policy, and in case of closure, shall contact their preceptor directly for instructions.

1. Provide the student with verbal constructive feedback, midway and throughout the rotation.

Preceptor Evaluation The “Student Evaluation Form”, is to be completed by the preceptor. The preceptor is required to:

2. Provide a written “Student Evaluation” and constructive feedback at the conclusion of the rotation. 3. Provide a copy of the written “Student Evaluation” to the student. 4. Post on the E*Value website, email, mail or fax a copy of the written “Student Evaluation” to the

Director of Experiential Programs within two week following the completion of each rotation. (701-231-7606)


Student Evaluations A Student Evaluation must be completed for all eight (8) rotations and registered on the E*Value website, emailed, mailed or faxed to the Director of Experiential Program within one week following the completion of each rotation. A student will not receive their graduation diploma if all evaluations are not received within two weeks of the end date of rotations. It is recommended that this evaluation be discussed with the preceptor during the feedback session at the conclusion of the rotation. These comments and observations will provide the preceptor with invaluable feedback regarding his/her site, service, and individual performance as a preceptor. Grading System The Grading System used to monitor academic performance for the Advanced Pharmacy Experience consists of: P (Pass): Indicates that the student has successfully completed the work of the Advanced Pharmacy Experience. F (Fail): Indicates either that student performance was unsatisfactory or that the student did not complete the work of the Advanced Pharmacy Experience.

THIS FORM MUST BE RETURNED TO THE BOARD OF PHARMACY WITHIN 5 DAYS AFTER COMPLETION OF ALL EIGHT (8) EXPERIENTIAL ROTATIONS

NORTH DAKOTA STATE BOARD OF PHARMACY

PO Box 1354 Bismarck, ND 58502-1354 Phone: 701-328-9535 Fax: 701-328-9536

Email: [email protected] Website: www.nodakpharmacy.com

AFFIDAVIT OF LICENSED PHARMACISTS/PRECEPTORS

MUST BE LEGIBLY WRITTEN

−

1

was under the following Licensed Pharmacist/Preceptors (Name of Licensed Intern Pharmacist) (Intern No.) for the Experiential Program Rotations approved by the North Dakota State Board of Pharmacy. if on rotation you: Dispense Compound

Community Advanced Practice 200 Hours

Credit

Dates Signature of Licensed Pharmacist/Preceptor State License No.

2 Hospital Advanced Practice 200 Hours

Credit


3 Adult Medicine 200 Hours

Credit


4 Rural Community Practice 200 Hours

Credit


5 (Indicate Elective Rotation) 200 Hours

Credit Signature of Licensed Pharmacist/Preceptor State License No.

Dates 6 (Indicate Elective Rotation) 200 License No.

Hours Credit

Signature of Licensed Pharmacist/Preceptor State License No.

Dates 7 (Indicate Elective Rotation) 200 Hours


Dates



Dates

Total Hours = 1600

THE ABOVE TOTAL HOURS ARE ACCEPTED AND APPROVED BY THE NORTH DAKOTA STATE BOARD OF PHARMACY.

AFFIDAVIT FROM THE DEAN OF THE COLLEGE OF PHARMACY

This is to certify has completed 1600 hours of Full Name of Licensed Intern Intern License Number Experiential Program as required by the North Dakota State Board of Pharmacy Practice Act Laws/Rules and has graduated from North Dakota State University College of Pharmacy, ____________ year curriculum on _________________________________ Graduation Date with a ________________ degree. Dean Subscribed and sworn to before me this day of A.D. Notary Public



PROGRESS REPORT OF LICENSED INTERN PHARMACIST

Progress Report to be completed by Licensed Intern Pharmacist after completion of each experiential rotation. 1. COMMUNITY ADVANCED PRACTICE ROTATION:

a. Briefly describe this experiential rotation: b. Objectives/goals of rotation : SATISFACTORY UNSATISFACTORY NEEDS IMPROVEMENT

2. HOSPITAL ADVANCED PRACTICE ROTATION: a. Briefly describe this experiential rotation: b. Objectives/goals of rotation : SATISFACTORY UNSATISFACTORY NEEDS IMPROVEMENT

3. ADULT MEDICINE EXPERIENTIAL ROTATION:

a. Briefly describe this experiential rotation:

b. Objectives/goals of rotation : SATISFACTORY UNSATISFACTORY NEEDS IMPROVEMENT 4. RURAL COMMUNITY PRACTICE ROTATION:


5. (Name of elective experiential rotation)








I ATTEST THAT I COMPLETED EXPERIENTIAL ROTATIONS AS SHOWN ON THE ABOVE PROGRESS REPORT FORM UNDER THE DIRECT SUPERVISION OF THE LICENSED PHARMACIST WHO SIGNED ACCORDINGLY ON THE NOTARIZED AFFIDAVIT (opposite side of this form) IN ACCORDANCE WITH THE LAWS AND RULES OF THE NORTH DAKOTA STATE BOARD OF PHARMACY. Signature of Licensed Intern Pharmacist Intern Number Date

5/1/20094:13 PM16. Copy of ADULT MED APPE Experience1

Adult Medicine Advanced Pharmacy Experience Goal: The goal of the Adult Medicine Advanced Pharmacy Experience is to provide students with a practical experience in applying their pharmacotherapeutic knowledge in the treatment of adult medicine patients in an inpatient and/or ambulatory care setting.

1. Develop an understanding of core patient disease states.

Objectives: After completion of this rotation the student will be able to:

2. Recommend appropriate pharmacotherapy for diseases commonly diagnosed in adults. Specifically

students will be able to: a. Explain the underlying pathophysiology of diseases commonly diagnosed in adults. b. Recommend appropriate pharmacologic treatment of these diseases to include:

i. Optimum drug regimen ii. Monitoring for efficacy

iii. Prevention and management of known adverse effects

3. Develop oral and written communication skills to better communicate with patients and other healthcare providers.

4. Evaluate, analyze, and solve complex patient problems through application of the knowledge gained

during didactic portions of the pharmacy program.

1. Students will attend and actively participate in assigned patient care rounds. Students will maintain a patient profile on the selection of pharmacologic treatments and monitor for response and adverse effects.

Activities:

2. Students will provide drug information (verbally or in writing) to nurses, physicians, peers, patients

and others as assigned by the preceptor.

3. Students will frequently review cases with the preceptor. The preceptor needs to be available for the discussion of patients, problems, situations, to provide feedback, instruction, and supervision.

4. Students will attend and participate in Pharmacy Case Conferences. If applicable, a formal

presentation of a case will be done every two weeks.

5. Students will attend assigned noon conferences, grand rounds, CE programs, and journal clubs. Presentations will be made by students when requested.

6. When requested, the student will advise and counsel patients and their families on the appropriate use

of drugs, monitor the effects of drug therapy, observe, identify, and discuss outcomes.

7. When assigned by the preceptor, the student will document adverse drug reactions utilizing pharmacy

5/1/20094:13 PM16. Copy of ADULT MED APPE Experience2

reporting forms and submit to the FDA when necessary.

8. Anticipate, identify, and, under the supervision of the preceptor, correct any drug therapy problem such as: a. wrong indication b. wrong dose

c. wrong dosage frequency d. wrong or excessive duration of therapy e. polypharmacy (too many total drugs or too many drugs per indication) f. adverse drug reaction g. wrong monitoring for drug efficacy or toxicity (problem with either too little monitoring or

too much monitoring) h. drug allergy I. wrong drug administration j. patient compliance k. no drug response l. excessive drug therapy costs 9. When requested by the preceptor or attending physician, the student will interview and complete a

patient assessment. At a minimum this should include: a. a list of current drugs and dosing schedules b. a list of pertinent past medications c. a list and description of drugs and other allergies and adverse drug effects d. an assessment of the patient's compliance to drug therapy e. a list of non-prescription drugs and/or social drug use f. assessment of medication efficacy

10. At the discretion of the preceptor, the student will complete a written or oral examination, to verify competency in a given area.

5/1/20094:13 PM17. Copy of COMMUNITY APPE Experience1

Community Advanced Pharmacy Practice Experience

Goals: This experiential academic program is a structured course in which preceptors supervise a pharmacy student in a community or hospital based pharmacy practice settings. The student gains practical experience in providing patient care services and applying the basic and pharmaceutical sciences in professional practice. The student will learn to make decisions based on professional knowledge and judgment, as well as gaining a practical awareness and understanding of the administrative, marketing, financial, and personnel components of community pharmacy management. Objectives: After completion of this rotation the student will be able to: 1. Interpret and evaluate a prescription or physician's order. 2. Observe and discuss consultative services to other professionals, as applicable. 3. Review prescriber conflicts or problems with the preceptor. 4. Determine the legality of the order based on state and federal laws and regulations. 5. Identify and resolve ethical concerns. 6. Choose, fill, and dispense the appropriate drug product. 7. Provide appropriate patient consultation services, as mandated by professional standards and state and

federal laws and regulations. 8. Provide consultation services regarding choice and use of OTC products, prescription accessories,

appliances, and devices. 9. Discuss management concerns regarding operational functions such as purchasing, inventory control,

marketing, pricing, third-party claims, accounting and financial analysis, and personnel management. Activities: 1. Specific hours and days of attendance will be set by the preceptor. The student's schedule should be as

similar to the preceptor's as possible, including all available work shifts. 2. The student must be present and active in assigned activities for a minimum of forty hours per week.

The student must have at least one day per week off. 3. The student will make up any missed hours regardless of the reason for the missed time. 4. At the discretion of the preceptor, the student will complete a written or oral examination, to verify

competency in a given area.

18. Copy of HOSPITAL APPE Experience.updated 3.14.071

Hospital Advanced Practice Experience

Goals: This experiential academic program is a structured course in which preceptors supervise a pharmacy student in a hospital based pharmacy practice setting. The student gains practical experience in providing patient care services and applying the basic pharmaceutical sciences in professional practice. The student will learn to make decisions based on professional knowledge and judgment, as well as gaining a practical awareness and understanding of the administrative, marketing, financial, satellites, and personnel components of hospital pharmacy management.

1. Interpret and evaluate medication orders for appropriateness with respect to the patient medication profile.

Objectives: After completion of this rotation the student will be able to:

2. Observe and discuss consultative services to other professionals and departments within the hospital setting.

3. Review prescriber conflicts or problems with the preceptor. 4. Demonstrate appropriate behavior and work ethics. Identify and discuss ethical concerns with

preceptor. 5. Discuss the difference between in and out patient services within the hospital setting. 6. When appropriate, choose, fill, and dispense the appropriate medications. Observe robotics and other

technology within the hospital pharmacy environment. 7. Demonstrate knowledge and skills regarding unit dose and intravenous admixture systems. Choose,

fill, and dispense appropriate intravenous medications as prescribed by the physician. 8. Provide patient consultation services, as mandated by professional standards and state and federal

laws and regulations. 9. Discuss hospital management concerns regarding operational functions such as purchasing, inventory

control, marketing, pricing, third-party claims, accounting and financial analysis, and personnel management.

10. Demonstrate knowledge and understanding of the activities of a hospital pharmacy, such as drug delivery systems, parenteral procedures, manufacturing requirements, clinical services, drug information services, and administrative concerns.

11. Describe the fundamental duties and operations of the committees in which pharmacy participates. 12. Demonstrate an understanding of JCAHO Medication Management standards and how the

department meets them. 13. Understand the role of the hospital and pharmacy departmental policy and procedures manual, and

the role of the pharmacy in the development of this document. Activities: 1. Specific hours and days of attendance will be communicated by the preceptor at the beginning of the

rotation. Preceptors are encouraged to have the student experience different shifts resulting in different experiences.

2. The student must be present and active in assigned activities for a minimum of forty hours per week. The student must have at least one day per week off.

3. The student will make up any missed hours regardless of the reason for the missed time. 4. At the discretion of the preceptor, the student will complete a written or oral examination, to verify

competency in a given area.

5/1/20094:04 PM19. Copy of RURAL APPE Experience1

Rural Advanced Pharmacy Experience Goal: To provide students with a broad-based learning experience in a rural setting where a community pharmacy also serves the area through services provided to long-term care facilities and/or community hospital services. The working definition of “rural” is a community with a population of less than 5,000 people. Objectives: After completion of this rotation the student will be able to: 1. Interpret and evaluate a prescription or physician's order. 2. Provide consultative services to other professionals, as applicable. 3. Resolve conflicts or problems with the prescriber. 4. Determine the legality of the order based on state and federal laws and regulations. 5. Identify and resolve ethical concerns. 6. Choose, fill, and dispense the appropriate drug product. 7. Provide appropriate patient consultation services, as mandated by professional standards and state and

federal laws and regulations. 8. Provide consultation services regarding choice and use of OTC products, prescription accessories,

appliances, and devices. 9. Discuss management concerns regarding operational functions such as purchasing, inventory control,

marketing, pricing, third-party claims, accounting and financial analysis, and personnel management. 10. Identify and learn the individual areas of expertise and need within the rural setting pharmacy, the

activities of a rural pharmacy, and involvement of the pharmacy in a rural community.

Activities:

1. Students will actively participate, when legal and possible, in all daily activities of the pharmacist at the site.

2. Students will effectively counsel patients/consumers when assigned, requested.

3. Students will present a least one public presentation on a topic of interest to a given population (i.e. nursing home staff, PTA).

5/1/20094:15 PM20. APPE Housing contacts.sites1

NDSU College of Pharmacy Rural Pharmacists Housing Information

2009-2010

Keaveny Drug 205 Broadway Ave S PO Box 340 Cokato MN 55321 Kelly Keaveny, R.Ph. (320) 286-5483 [email protected] Community/Nursing Home Kelly has a 6 bedroom house He is willing to house students at his home. Turtle Lake Drug 218 E Main, PO Box 70 Turtle Lake ND 58575 Mark Malzer, R.Ph. (701) 448-2542 Nursing Home/Hospital Furnished Apartment - Don Cullum (701) 448-9125 Service Drug 8115 Lincoln Ave Harvey ND 58341 Gordon Mayer, R.Ph. (701) 324-2227 [email protected] Nursing Home/Hospital Gordon possibly can arrange for the store to rent an apartment for the student.

Seaburg Drug/Carrington Health Care Pharmacy/Seaburg Drug-New Rockford 990 Main St Carrington ND 58421 Tom Seaburg, R.Ph., Shane Wendahl, R.Ph., Matt Paulson, R.Ph. (701) 652-2651 [email protected] 4 Nursing Homes, 2 Group Homes, PCCA approved - compounding pharmacy Seaburg Drug will help find housing. They will take 2 students at a time and will help subsidize housing for students.

Killdeer Pharmacy PO Box 745, 14 S Central Ave Kildeer ND 58640 Jody Doe, R.Ph. (701) 764-5093 [email protected] Tele-Pharmacy/Nursing Home Mountain View Motel

Linda Truchan (701)764-5843


Paul Bilden Pharmacy 10 North Main St Northwood ND 58267 Wade Bilden, R.Ph. (701) 587-5271 [email protected] 2 Nursing Homes/Hospital Paul Bilden Pharmacy will help find housing Thrifty White Drug PO Box 750 Hettinger ND 58639 Gary Dewhirst, R.Ph. (701) 567-2533 [email protected] Nursing Homes & Assisted Living Beds Thrifty White Drug will help find housing White Drug PO Box 249, 201 E 3rd Ave S Cavalier ND 58220 Dr. Mark Hardy, Pharm.D. (701) 265-4744

One bedroom house, partially furnished, about 6 blocks from the store. The owner is willing to negotiate on rent/utilities.

2 bedroom trailer, same owner, same negotiations, 1 block further away from the store

Owner’s David Hartz phone numbers are: 265-4329 (H) 520-0270 (C) White Drug 107 2nd St SE Rugby ND 58368 Kyle DeMontigny, R.Ph. (701) 776-5741 Nursing Home Hub Motel (701) 776-5833

Beulah Drug 147 W Main, Box 99 Beulah ND 58523 David Just, R.Ph. (701) 873-5215 [email protected] Nursing Home


Wishek Drug PO Box 217, 9 S. Centennial St Wishek ND 58495 Carla Alpperspach, R.Ph. (701) 452-2368 [email protected] Nursing Home/Hospital Stardust Hotel - converted into apartments Val Roadweeder (701) 452-2184(H) or (W) (701) 452-3108

Langdon Community Drug 706 3rd St Langdon ND 58249 Dr. Lyle Lutman, Pharm.D. (701) 256-3330 [email protected] Nursing Home/Hospital PCCA Compounding Pharmacy Located downtown upstairs of two large department stores Furnished apartment where cable, electric and telephone are in renters name 1 or 2 bedrooms. Sleeping room about 5 blocks from store, off street parking private bath and a television. Langdon Motor Inn. Towner County Medical Center Highway 281 N Cando ND 58324 Rusty (Ruth Ann) Held, R.Ph. (701) 968-2525 – Possibly free housing available at Hospital Hospital 20 beds, Basic Care - 10 units, Center for Solutions - alcohol,drug dependence (med fill), assisted living Kenmare Drug PO Box 895, 109 1st Ave NW Kenmare ND 58746-0895 Kim Esler, R.Ph. (701) 385-4257

Kenmare Community Hospital/Nursing Home Kenmare Drug will help find housing.

Mercy Hospital, Valley City, ND 570 Chatauqua Blvd Valley City, ND 58072 Dr. Amy Noeske, Pharm.D. (701) 845-6437

Free food for students available in the Hospital Cafeteria. The Hospital owns a duplex across the parking lot from the Hospital, possibly free housing is available there.


Grand Forks Area UND Guest Housing Ali Blackman Wilkerson Complex Secretary 701-777-2779 www.housing.und.edu Cost for a room (2 single beds) is $28 per night. Ye Olde Medicine Center 103 Harris Ave. S Park River, ND 58270 Laurie Larson, R.Ph.

(800) 226-7676 Free Housing available, paid by preceptor. Noon meals paid by preceptor.

Tara’s Thrifty White Pharamacy or Southeast Medical Center 610 Main Ave Oakes, ND 58474 Dr. Tara Schmitz, Pharm.D. 701-742-3267 Housing Available: $100/week (includes 1 meal/day at local cafe) It is a room for rent with a king sized bed, 1200 square foot basement living accommodations, sauna, pool table, exercise equipment, internet/computer access, and separate entrance. Owners are Dr. Schmitz’s parents.

http://www.housing.und.edu/�


Housing Directors for North Dakota State Universities and Colleges Director of Student Life/Housing Director of Residence Services Lisa Eriksmoen Denise Adams Minot State University University of North Dakota 500 University Ave W Box 9029 Minot ND 58707 Grand Forks ND 58202-9029 (701) 858-3363 (701) 777-4254 Director of Residence Life Director of Housing Gary Vanvindern Stephanie Roelfsema Jamestown State College Valley City State University 608 NE 6th St VCSU Student Center Jamestown ND 58401 Valley City ND 58072 (701) 252-3467 (701) 845-7728 Director of Student Affairs Asst. Director of Housing/Security Paula Berg Julia Peterson MSU-Bottineau Mayville State University 105 Simrall Blvd 330 NE 3rd St Bottineau ND 58318 Mayville ND 58257-1299 (701) 228-5451 (701) 788-4842 Director of Housing Housing Coordinator Randy Fixen Barb Berns UND-Lake Region St. Alexius Medical Center 1801 N College Dr 900 E Broadway Devils Lake ND 58301 Bismarck ND 58502 (701) 662-1518 (701) 530-5670 Director of Residence Life Coordinator of Residential Life Michael Harwood Howl Hanes North Dakota State University Dickinson State University Auxiliary Building 101C Seilke Hall Fargo ND 58105 Dickinson ND 58601 (701) 231-8023 (701) 483-2091

Director of Residence Services NDSU Housing Manager Norman Coley Ryan NDSCS North Dakota State University 800 N 6th St 701-231-7890 Wahpeton ND 58076 (701) 671-2520 Director of Housing Heidi Williston State College 701-774-4528

Elective Advanced Pharmacy Experiences

Goals:

The specific goals/objectives of each Elective Advanced Pharmacy Experience rotation will be dependent on the type of setting and established by the preceptor, the student, and the Director of Experiential Programs.

Objectives:

After completion of the individual rotations the student will be able to:

1. Interpret and evaluate pharmacist and physician orders. 2. Provide consultative services to the pharmacist, physicians, and other professionals, as

applicable.

3. Resolve conflicts or problems with the prescriber.

4. Determine the legality of the order based on state and federal laws and regulations.

5. Identify and address ethical concerns.

6. Choose, fill, and dispense the appropriate drug product.

7. Provide appropriate patient consultation services, as mandated by professional standards and state and federal laws and regulations.

8. Discuss management concerns regarding operational functions such as purchasing,

inventory control, marketing, pricing, third-party claims, accounting and financial analysis, and personnel management as they apply to individual sites/experiences.

9. Identify and seek to understand the activities related to good pharmacy practice within

each individual site/experience.

Activities:

Independent activities will be assigned based on the individual site and the student goals/needs.

5/1/20094:16 PM22. IHS Housing contacts.sites

NDSU College of Pharmacy Indian Health Services Contact Information

2009-2010

Pharmacy www.pharmacy.ihs.gov

Physician and Other Health Care Professionals

www.ihs.gov Nursing www.nursing.ihs.gov Environmental Health www.dehs.ihs.gov

Dentists www.dental.ihs.gov

USPHS Indian Health Service - Belcourt Pharmacy Dept., Hospital Road Belcourt, ND 58316 Stephen Dienes, R.Ph. (701) 477-8422 Possibly free lodging. USPHS Indian Health Service PO Box J Fort Yates, ND 58538 Dr. Billy St. Claire, Pharm.D. (701) 854-8340 Possible housing (sometimes free). USPHS Indian Health Service 1 Minni-Tohe Drive New Town, ND 58763 Dr. Wayne Marmon, Pharm.D. (701) 627-7945 Very little lodging, but will try to work with students.

USPHS Indian Health Service 3200 Canyon Lake Dr. Rapid City, SD 57702 Dr. Todd Campbell, Pharm.D.

(605) 355-22393 USPHS Indian Health Service Box 729; 550 6th

Possible housing available at $10/day (this includes breakfast and dinner). Call Shirley Vandall at 406-653-2663.

Ave. N. Wolf Point, MT 59201

Student Dress Code for Concept Pharmacy, Experiential Education, and Outreach Activities

Purpose This dress code outlines the minimal acceptable standard for dress and appearance expected and required of all students during Concept Pharmacy, introductory pharmacy practice experiences (IPPE), advanced pharmacy practice experiences (APPE), and outreach activities. Within the Concept Pharmacy and during IPPE, and APPE, and outreach activities there are various levels of patient and public contact that require attention to appearance. This dress code will address basic expectations relating to professionalism and safety, recognizing that experiential education sites and outreach activities may modify the dress codes to be consistent with the work and public contact specific to them. The goals of the dress code are twofold (1) promote a professional impression on patients, the public, faculty, and preceptors, and (2) promote safety. Compliance and Enforcement Standards of dress and personal appearance will be communicated during Concept Pharmacy, experiential education, and outreach activity orientations. When a student’s dress does not comply with the established standard, the Concept Pharmacy course coordinator, experiential education preceptor, or outreach activity coordinator will take appropriate action.

Concept Pharmacy Deviations from professional dress will result in a professional infraction (PI). These decisions will be made by Concept Pharmacy faculty. If a student receives three professional infractions, they will be required to complete a reflective composition on professionalism. Experiential Education Sites Deviations from professional dress will result in a discussion between the preceptor and the student. If counseling fails to bring the desired response the experiential director will be contacted.

If for religious, cultural, or medical reasons there is a need to deviate from the dress code, the student must submit a written request for exception to the Concept Pharmacy course coordinator or experiential director.

Consistent application of the dress code is expected of all Concept Pharmacy faculty, experiential directors, and experiential education preceptors. The dress code is not all inclusive. Students who have questions or seek clarification should consult with Concept Pharmacy faculty, the experiential director, or their experiential education preceptor. Outreach Activities The dress code will be maintained in the following circumstances: When participating in local, regional, or national pharmacy meetings or officially representing the College

of Pharmacy, Nursing, and Allied Sciences during educational in-services or poster presentations.

Exceptions may be permitted per experiential education preceptors or outreach activity coordinators, who will exercise judgment and discretion when appropriate.

Name tag/ Lab coats Each student will receive a name tag and lab coat or name embroidered lab coat. These items are recognized as the principal basis of identification for faculty, preceptors, patients, and the public. These items must be worn during Concept Pharmacy, experiential education experiences, and outreach activities or when officially representing the College of Pharmacy, Nursing, and Allied Sciences. Lab coats must be clean and pressed. Lost, misplaced, or stolen name tags or lab coats must be reported

to the Dean’s office and replaced. All clothing should be clean, fit properly, be in good repair and pressed as needed.

Examples of appropriate and inappropriate dress for the College of Pharmacy, Nursing, and Allied Sciences are available on the North Dakota State University Dress for Success website: http://www.ndsu.nodak.edu/career_center/dfssite/index.php. Men will wear a dress shirt, tie, full-length dress pants, and coordinating dress shoes. Women will wear a blouse or sweater with a skirt or dress pants or a dress, and coordinating dress

shoes.

Head coverings may be worn when associated with religious, cultural, or medical reasons. Visible pierced body jewelry is limited to two small pairs of earrings in earlobes. Jewelry should be conservative in style and kept at a minimum. All visible tattoos must be covered.

Recommendations for body art are available on the North Dakota State University Dress for Success website: http://www.ndsu.nodak.edu/career_center/dfssite/index.php.

Grooming and Hygiene Attention to hygiene is critical to the professional appearance and perception of a health care professional. Hair should be clean and well groomed. Beards, mustaches, and sideburns are to be neatly trimmed. Cosmetics should be worn in moderation. Perfumes, colognes, or heavy fragrances should not be worn. Fingernails must be clean, short, and neatly trimmed. Clear or light colored nail polish is acceptable. Extreme nail polish colors or artificial fingernails, tips, wraps, or fillers may not be worn. Uniforms/Scrubs Students may be required to wear uniforms or scrubs appropriate to the experiential education site.

When reporting to an experiential education site, the uniform should be complete and consistent with the

site standard.

http://www.ndsu.nodak.edu/career_center/dfssite/index.php�

http://www.ndsu.nodak.edu/career_center/dfssite/index.php�

Inappropriate Attire The following attire is not permitted in the Concept Pharmacy or at experiential education sites: Clothing more appropriate for sports, lounge, or social wear

Clothing with print or logos Sheer or revealing clothing T-shirts, tank tops, halter tops Mini-skirts, dresses or skirts with high slits Sweat pants, carpenter pants, warm up pants, tights when worn as pants, or leggings Denim jeans or any pants resembling jeans, regardless of color of fabric Head gear including hats, baseball caps, stocking hats, sweatbands, and bandannas Sunglasses or dark glasses indoors, unless worn for medical reasons Open toed shoes, flip-flops, or tennis shoes

Inappropriate Behaviors Arriving late to Concept Pharmacy, experiential education experiences, or outreach activities is

unacceptable.

Gum chewing is prohibited during Concept Pharmacy, experiential education experiences, and outreach activities.

The use of earphones, headphones, mp3 players, iPods, or cell phones are not permitted during Concept

Pharmacy, experiential education experiences, and outreach activities.

Gary W. Dewhirst, R.Ph. Hettinger, President

Rick L. Detwiller, R.Ph. Bismarck

OFFICE OF THE EXECUTIVE DIRECTOR Laurel Haroldson, R.Ph. P O Box 1354 Jamestown

Bismarck ND 58502-1354 Bonnie J. Thom, R.Ph. Telephone (701) 328-9535 Granville

BOARD OF PHARMACY Fax (701) 328-9536 Gayle D. Ziegler, R.Ph. State of North Dakota Fargo

www.nodakpharmacy.com William J. Grosz, Sc.D., R.Ph. John Hoeven, Governor E-mail= [email protected] Wahpeton, Treasurer Howard C. Anderson, Jr, R.Ph.

Executive Director March 2009 To: P4 Students From: Howard C. Anderson, Jr., R.Ph. Executive Director RE: AFFIDAVIT/PROGRESS REPORT FORMS FOR 2009 - 2010 PERSONAL PORTFOLIO INFORMATION Affidavit/Progress Report Form The Affidavit and Progress Report Forms are used as the permanent record of your experiential experiences and graduation verification. The Board uses the signature portion at the bottom of these forms to certify your eligibility to take the NAPLEX and to certify these hours to other states should you chose to take other board examinations. Therefore, these forms are REQUIRED

even if you do not plan to take the ND boards. You may want to copy them periodically so that you have a record of all pertinent information including the names of the people who signed the affidavit and the dates it was signed, should you need to reproduce the form. It is important to remember that you may NOT submit a photocopy of these forms should you lose the originals. You must have all ORIGINAL signatures for certification.

The affidavit needs to be filled out legibly or typed either on a typewriter or using the form online at www.nodakpharmacy.com, which can then be printed for your use. On the front page of the affidavit, there are two columns of boxes. These are going to be used as an indication of your participation in dispensing and compounding activities. Please check the dispensing box if you were involved in dispensing activities at that site. Check the compounding box if you were involved in what you feel is a reasonable amount of compounding at that site. Therefore, you can check no boxes, one box or both depending on what you feel you were exposed to at that site. Personal Portfolio Information: Please see the “P4 E*Value Personal Portfolio Requirements for the ND Board of Pharmacy” which is located under the “Student Information” tab in your APPE manual. This table is a reference to the information summarized below. (For E*Value instructions, please refer to the E*Value information in your manual) You are encouraged to work on this portfolio throughout the upcoming year. This personal portfolio is REQUIRED

of each NDSU College of Pharmacy Student. You will have to submit the portfolio even if you do not plan to take ND Boards. If we are to accept your hours, even for transfer, you must complete the process. The Board will use the information to evaluate your experience as well as the practical experience in general. The College will use the portfolio to assess their program of professional practice to meet the College’s requirements for accreditation with the American College on Pharmaceutical Education (ACPE) Standards.


The summary should be at least one page long and include the name of the pharmacy or location of the rotation, the name of your preceptor(s), the dates, and a brief description of the rotation. The brief description of the rotation should include any major or minor projects you worked on, the duties you had while at the rotation, seminars you attended or conducted, and other miscellaneous information about the site (how many scripts they do per day, how many cholesterol checks they average, the goal of the pharmacy, type of staff and patients you worked with, etc.). Also, include a list of goals and learning objectives and a column next to each goal/objective indicating whether or not these goals/objectives were achieved. Goals may be taken from the rotational experience booklet, College of Pharmacy website, and/or written or verbal goals given to you by your preceptor. This can be on the same page as the summary or on a separate page, whichever you feel is appropriate. Please be honest if the goals/objectives were indeed met, it helps us evaluate the quality of your learning experience. There should also be two pharmaceutical care plans written up in any format you choose. If you see patients you are expected to write care plans;

this includes every rotation except those such as management, research or education. For community externships, a care plan could be as simple as writing up an assessment on a patient’s medication using the guidelines on the attached page. When preparing pharmaceutical care plans for your portfolio, please be cognizant of confidentiality issues related to patient personal information.

In addition, a report of special activities you participated in (health fairs, brown bag seminars, etc.), projects or presentations done during the rotation (including feedback on those projects as well as handouts and notes on any presentation you may have made) and special tidbits such as new or uncommon drugs used is recommended. The following are additional examples of what might be included in this section: written reports submitted to your preceptor or reports you helped your preceptor compile, calculations and instructions on how you prepared a very different or interesting compound, and/or information you may have researched for a preceptor, patient, nurse, or physician (include where you found the information and how it helped the individual). You could also include a write up of drug information consultations and oral consultations. Consultation examples might include your best patient consultation, how you answered a specific question, gave information on a new medication or one unfamiliar to yourself, or helped to find the best OTC product for a certain patient. Please, annotate at the end any abbreviations or acronyms you used in the report. When using location, physician or student names, please use the complete names, as Board members and faculty reviewers are not as cognizant of them as you are. Finally, the assessment page should briefly describe the quality of the preceptor and site. Here you should take in to consideration if there was adequate time, space and resources to meet the goals and objectives. We would also like to know if you would recommend this preceptor or site to others. At the end of your portfolio, in a separate section, you should include an essay (1-2 pages in length) that summarizes the impact of your rotations on expanding your knowledge base, overall professional growth, and career choice. Your essay should also discuss your four years of professional education including which faculty, course work, and extracurricular activities contributed most to your professional growth. This essay will be shared with the College of Pharmacy Assessment Committee, both for feedback to the College, and to assess your overall writing skills.

Please remember you MUST notify the Board of any changes in your permanent address and/or other contact information so that we may keep our records up to date. If you have any questions feel free to contact the Board Office at (701) 328-9535 or by e-mail at [email protected]= Howard or [email protected] =Eileen.



5/1/2009 4:17 PM

P4 E*Value Personal Portfolio Requirements for the ND Board of Pharmacy

P4 Rotation Assignments Description Affidavit/Progress Report Form This form requires preceptor signatures/dates from each

rotation. A copy should exist in the portfolio, but completion of the form will not occur on line as we would need electronic signatures from each preceptor.

Summary of each The summary should be at least one page long. See attachment.

Rotation

Pharmaceutical Care Plan I & II If the student has contact with patients, two pharmaceutical care plans are required. This includes every rotation except those such as management, research, or academic rotations. See attachment for pharmaceutical plan requirements.

Special Activities/Projects A report of special activities/projects done during the rotation: 1. Health fairs 2. Brown bag seminars 3. Immunization clinics 4. Written reports for your preceptors 5. Calculations/preparation instructions on a compound 6. Researched information 7. Your best consultations, how you answered a patient

question, information provided for a new medication, etc.

8. Include feedback on those projects as well as handouts and notes on any presentation that was made.

Site/preceptor Assessment Provide a brief assessment describing the quality of the preceptor and site. Take into consideration the time, space, and resources to meet the goals and objectives for the rotation. Please include a personal recommendation of the site/preceptor.

Summary of Educational Experience/s Provide a written 2 page essay which includes the following: 1. Summarize the impact of your rotation on expanding

your knowledge base. 2. Overall professional growth during the professional

program. 3. Discuss your opinion of your career choice. 4. Discuss the four years of professional education including

which faculty, course work, and extracurricular activities contributed most to your professional growth.

Attachments include: 1. Affidavit 2. Expectations of the rotation

summary 3. Pharmaceutical Care Plan

(suggested) format

G:\Pharmacy\Website\2009-2010 APPE Manual\26. Personal Portfolio Information.doc5/1/20094:18 PM 1

PERSONAL PORTFOLIO INFORMATION

1. Summary page to include: a. name of pharmacy or location of rotation b. name of preceptor c. dates working d. a brief description of the rotation: this includes any major or minor projects you worked on,

the duties you had while at the rotation, seminars you attended or conducted, and other miscellaneous information about the site (how many scripts they do per day, how many cholesterol checks they average, the goal of the pharmacy, type of staff and patients you worked with).

e. A list of goals and learning objectives and a column next to each goal/objective indicating whether or not these goals/objectives were achieved. Please be honest if the goals/objectives were indeed met, it helps the board evaluate the site. Goals may be taken from:

i. Advanced Pharmacy Experience manual. Goals and objectives outlined for specific rotations.

ii. E*Value website iii. The goals the preceptor presents you with at the beginning of the rotation (Either in

writing or verbally. You may want to write down the goals they present you if given verbally.)

iv. Personal goals for specific rotations.

2. Pharmaceutical Care Plans Care plans are a requirement for all rotations where patient care or exposure to patient care occurs. Please review the letter from the ND State Board which can be found at the end of this section in your binder, referencing pharmaceutical care plans. The NDSU Pharmacy Practice Guidelines for writing pharmaceutical care plans are also included. You do not have to use this exact format.

a. basic information about the patient (why are they being seen, medical history, description of pt.)

You may present your patient in any way you choose. The Board of Pharmacy is looking for:

b. problem or problems the patient is experiencing and the findings (laboratory, physical, and subjective parameters)

c. what your plan is for the patient and how you are to achieve this plan (therapeutic endpoint of therapy and how these endpoints can be measured and monitored).

The following page illustrates an example of a care plan using a cholesterol screening. You would also include a little paragraph describing the patient, listing any medications they are currently taking and their medical history.

G:\Pharmacy\Website\2009-2010 APPE Manual\26. Personal Portfolio Information.doc5/1/20094:18 PM 2

Hyperlipidemia

Findings Therapeutic Goals

Recommendations Monitoring Parameters and

Frequency

Desired Endpoint

Patient Education

TC= 202 mg/dl TG = 186 HDL = 52 TC/HDL = 4.3%

Decrease TC and TG and keep other values within range as well

TC and TG are borderline at this time. Have patient watch diet for foods containing high cholesterol. (May inform doctor of values in a letter.)

Have values checked again in 3 months.

TC<200 TG<150 HDL>50 TC/HDL<4.5%

Gave patient cholesterol information and food to choose/avoid. Explained risks of having high cholesterol.

Reports: In addition to pharmaceutical care plans, the following may be included in your personal portfolio:

• Written reports submitted to your preceptor. • Presentations and any handouts you prepared. • Reports on special activities you participated in (health fairs, brown bag seminars, etc..) • Calculations and instructions on how you prepared a very different or interesting

compound. • Information you may have researched for a preceptor, patient, nurse, or physician (include

references and the impact to health provider and/or patient) • Written documentation of patient counseling (This would be an example of your best

work while at the rotation. Detail your best patient consultation, your answer to a specific patient/health provider question, information given on a new medication, or help regarding the best OTC product for a certain disease state.)

3. Evaluation/Assessment Page:

a. Describe the quality of the preceptor and site. b. Did they have adequate time, space, or resources for you to meet your goals? c. Would you recommend this site to others? d. Why or why not?

5/1/2009 4:18 PM Pointers for writing pharm care plans

POINTS TO CONSIDER WHEN WRITING PHARMACEUTICAL CARE PLANS

Objectives and Evaluation: A. Given a patient's medical record, the student should be able to: 1. Identify, list and prioritize the significant active and inactive medical problems. 2. List the subjective and objective evidence for each problem. 3. Identify which of the above problems require drug therapy.

4. Identify those medical problems or laboratory values which may be induced or aggravated by present or future drug therapy.

5. Identify any potential drug interactions. 6. Assess the appropriateness of current therapy and design an individualized drug

therapy plan for each of the patient's problems. 7. Determine if p.r.n. medications are used properly.

POINT 8 CAN BE USED AS A GUIDE FOR CARE PLANS IN A COMMUNITY ADVANCED PRACTICE SITUATION

(Note: In Community Advanced ) 8. For each drug that the patient takes, the student will: a. Critically evaluate the rationale for its use in this particular patient.

b. Design a safe and effective dosing regimen for the patient. The impact that other medical problems (i.e. renal, liver or gastrointestinal disease) may have on the biopharmaceutic and pharmacokinetic parameters of the drug should also be considered.

c. Establish the therapeutic and toxic endpoints of therapy and how these endpoints can be measured and monitored.

d. List those laboratory, physical and subjective parameters which may be used to follow the therapeutic and toxic effects of the drug.

e. Look at any potential drug interactions.

G:\Pharmacy\Website\2009-2010 APPE Manual\28. Tips from former P4 Students.doc5/1/20094:18 PM 1

Be knowledgeable of common disease states (HTN/CHF/STDs/DM/dyslipidemia/etc.) In terms of pathophysiology, rationale for pharmacotherapy, and treatment guidelines.

Tips from former P4 Students

Always try to obtain or expand your knowledge base in any possible way (i.e. from talking to your preceptor, reference books, or even clients (ADRs)). Positive attitude always (no matter what the situation). If possible, continual review of disease states/medications throughout the rotations can be extremely helpful and will save you time when studying for boards. Write down all the activities done throughout the rotation, which will help you in writing your dossier (without having to try to remember it all). Cover all the topics which you may not be familiar with (i.e. OTCs if that is your weak area) with either your preceptor or reference books. Keep current with the practice of pharmacotherapy throughout your rotations. Never stop asking questions, no matter how mundane or rudimentary. Keep up on your personal portfolio. It is easier to sit down for one hour after you finish a rotation and write up a summary then to wait until the end of rotations and sit for several hours writing summaries. Try throughout the year (a little at a time) to study for board examinations. I didn’t do this and now I am feeling overwhelmed by the amount of material that I would like to review, but know that there is not sufficient time for me to do this before I take the boards. Try to call your next preceptor during the second to the last week of the current rotation. This will allow enough time to get in touch with the preceptor if they are on vacation that week or are working a different schedule. Have some fun since you do not have to study all the time. Relax! you all will do well. You have worked hard for the last 5+ years, enjoy learning in a different environment other than lecture halls. The best tip that I can give the P4's is to remember that they aren’t going to know everything as they go into the rotations. It’s okay if they are asked a question and don’t know it. Just go and look the information up. That’s the best way to learn, because in the end it’ll start coming together!

5/1/20094:19 PM29. Student Understanding Form 1

DEPARTMENT OF PHARMACY PRACTICE NORTH DAKOTA STATE UNIVERSITY

ADVANCED PHARMACY PRACTICE EXPERIENCE MEMORANDUM OF UNDERSTANDING

I wish to confirm to the Director of the Experiential Training Program, Wanda Roden, R.Ph., and the Department of Pharmacy Practice that: 1) I have satisfactorily completed (Grade C or better) all of my Pharm.D. III coursework. 2) I will not accept a Community/Hospital Advanced Pharmacy Practice Experience where I have worked for a salary. I will not request or accept pay or remuneration from the Advanced Pharmacy Practice Experience pharmacy or pharmacists. (Special situations involving consideration or assistance with room, board, or travel must have prior approval by the Experiential Program Director in writing.) 3) I will register for Pharm. Practice 581 (10 credits), 582 and 583 (15 credits). 4) I am registered as a Pharmacist Intern in the State of North Dakota. 5) If assigned an Advanced Pharmacy Practice Experience site outside of North Dakota, I am also registered as a Pharmacist Intern in (give name of state) and will comply with that state's rules and regulations. 6) I am insured with professional liability insurance by: (give name of company and dollar amount). I am insured by health insurance with: _________________________ (give name of company and policy number). 7) I have not nor will I register for other course work during the Advanced Pharmacy Practice Experience Program except as provided in the APPE Manual. 8) If employed on a part-time basis I will arrange my work schedule so as not to interfere with the Advanced Pharmacy Practice Experience Program. 9) I shall regard all information and/or activities of the pharmacy or relating to pharmacy and the medical community and the patients to be confidential and under no circumstances will knowledge so acquired be disclosed to unauthorized persons as failure to do so, if substantiated after due process, would result in my dismissal from the Advanced Pharmacy Practice Experience Program and my being subject to action by the College of Pharmacy. 10) I will conduct myself in a professional, straight-forward manner and will not create situations wherein there can be a question of my honesty or integrity as a charge of dishonesty, if substantiated after due process, would result in my dismissal from the Advanced Pharmacy Practice Experience Program and my being subject to action by the College of Pharmacy. ____________________ Student Signature Date Director of Experiential Program Date

5/1/20094:19 PM30. District V_preceptor eval by student

Professional Experience Program Site/Preceptor Evaluation Form

Student:

Date:

Preceptor:

Site:

Use the following scale to indicate your agreement with the following statements 5 = Strongly Agree 2 = Disagree 4 = Agree 1 = Strongly Disagree 3 = Neutral NA = Not applicable to the Rotation or Site The preceptor is interested in teaching this rotation. 6 5 4 3 2 1 NA The preceptor related to me as an individual. 6 5 4 3 2 1 NA The preceptor encouraged me to actively participate in discussions and problem-solving exercises.

6 5 4 3 2 1 NA

I had adequate patient or guardian contact on this rotation to meet the learning objectives.

6 5 4 3 2 1 NA

I had access to necessary patient information. 6 5 4 3 2 1 NA I was encouraged to access and use resource materials. 6 5 4 3 2 1 NA I had access to all necessary reference materials, either hard copy or via electronic means.

6 5 4 3 2 1 NA

The preceptor described their approach to thinking about therapeutic problems.

6 5 4 3 2 1 NA

The preceptor is readily available to answer questions and concerns. 6 5 4 3 2 1 NA The preceptor provided good direction and feedback. 6 5 4 3 2 1 NA The preceptor is knowledgeable in his/her response to questions regarding his/her approach to therapy..

6 5 4 3 2 1 NA

The preceptor evaluated me after two weeks on the rotation. 6 5 4 3 2 1 NA The preceptor evaluated me at the end of the rotation in a manner which was helpful to me

6 5 4 3 2 1 NA

The preceptor served as a role model for a pharmacist practicing in this practice setting.

6 5 4 3 2 1 NA

The rotation provided opportunities to interact with other health care professionals.

6 5 4 3 2 1 NA

The goals and objectives of the rotation were outlined and/or explained at the beginning of the rotation.

6 5 4 3 2 1 NA

Rotation activities were well organized and structured. 6 5 4 3 2 1 NA This rotation provided an environment (physical and philosophical) that facilitated my learning.

6 5 4 3 2 1 NA

Others at the rotation site were receptive and willing to interact with me. 6 5 4 3 2 1 NA My verbal communication skills were enhanced on this rotation. 6 5 4 3 2 1 NA My written communication skills or documentation skills were enhanced on this rotation.

6 5 4 3 2 1 NA

My clinical skills were enhanced on this rotation. 6 5 4 3 2 1 NA I was able to apply previously learned materials on this rotation. 6 5 4 3 2 1 NA I believe this experience will help me be a better pharmacist. 6 5 4 3 2 1 NA Fax number: 701-231-7606

5/1/20094:19 PM30. District V_preceptor eval by student

The preceptor discussed patient care and/or practice related issues with me an average of > 4 hours per day > 1 to 2 hours per day > 3 to 4 hours per day 0.5 to 1 hour per day > 2 to 3 hours per day < 0.5 hour per day Overall, how would you rate this practice experience? Excellent Good Fair Poor Please elaborate and give examples How might this practice experience be improved?

5/1/20094:20 PM31. Preceptor of the Year Policy

PRECEPTOR OF THE YEAR The Preceptor of the Year Award is selected by students in the experiential portion of professional program and recognizes preceptors who have demonstrated a commitment to and excellence in their approaches to student learning. One faculty preceptor and one volunteer preceptor will be selected each year for this award. The process for selection will be as follows:

A. The Director of Experiential Programs will remind P4 students to submit written or email nominations during the 7th

B. The committee of P4 students will be selected by the rotations committee. The students will come from a volunteer pool established through response to the email noted in “A”. These students, along with the Experiential Director in attendance, will meet and select the award recipients.

rotation. To encourage students to consider nominating “excellent” preceptors throughout the entire P4 year, a “Preceptor of the Year Nomination” form has been included in the P4 Rotation manual. This form is also included as page 3 of the “Student Evaluation of the Preceptor” form, and may be submitted along with the 5 week rotation evaluation form to the Director of Experiential Programs at any time during any rotation.

C. The selection will be based on the nominations and recommendations from the entire class, and will not necessarily be based on a raw numbers of votes.

D. The award recipient results will be forwarded to the Administrative Assistant to the Dean by the end of March to ensure time for awards to be processed. Each award recipient will be notified as to their selection. Their attendance at the Hooding Ceremony is strongly recommended for award presentation and recognition.

E. The award consists of a plaque and $1000.00 check.

PRECEPTOR OF THE YEAR NOMINATION: Please DO NOT complete if you would not consider this Preceptor for a potential “Preceptor of the Year” Award. These scores/comments will be tallied throughout the year and result in the selection of the “Preceptor of the Year”. Rank Preceptor attributes using the following designations: 3 = Excellent 2 = Very Good 1 = Average Your comments can make the difference between one preceptor receiving the Preceptor of the Year award and a preceptor not receiving the award. You comments are very important! ______ Preceptor is dedicated and is available to answer questions. Comments/Examples: ______ Preceptor makes me feel like an equal and values my thoughts an

opinions. Comments/Examples: ______ Preceptor fosters my future plans through a mentoring, personal, and

professional relationship. Comments/Examples: ______ Throughout the rotation, the Preceptor poses questions to test/enhance the

knowledge of the student. Comments/Examples: ______ Preceptor is approachable regarding ANY questsion, concern, or issue. Comments/Examples: Thank you for taking the time to complete this evaluation. Please return the completed evaluation to the Experiential Programs office. 118S Sudro Hall. Box 5055. North Dakota State University, Fargo, ND 58105 Fax number: 701-231-7606

5/1/20094:21 PM33. Annual Leave Form 1

North Dakota State University Department of Pharmacy Practice Pharm.D. Experiential Program ANNUAL LEAVE FORM This form is to be used for Personal Leave Days Only. A student is allowed 5 personal days during the 40 weeks, with no more than 2 days occurring during a 5 week rotation.. STUDENT NAME Total Days Requested (list dates) ___________________________________________ ___________________________________________ ___________________________________________ PRECEPTOR APPROVAL I have granted permission for the above student to take personal leave on the date(s) listed above. Preceptor's Signature __________________________________ Date: _______________ **************************************************************************** I have received permission from my preceptor to take personal on the dates listed above. Student's Signature __________________________________ Date _______________ Please return the completed form to: Director of Experiential Programs NDSU Dept. 2660 118S Sudro Hall, P.O. Box 6050 Fargo ND 58108-6050 Phone: 701-231-5178 Fax: 701-231-7606

5/1/20094:21 PM34. Rotation Assignment Change Request Form 1

North Dakota State University Department of Pharmacy Practice Pharm.D. Experiential Program

ROTATION ASSIGNMENT CHANGE REQUEST

Students: Students wishing to make a schedule change must first obtain verbal authorization from the Director of Experiential Programs. Rotation assignment changes require the permission and signature of both the preceptor of the originally scheduled rotation and the preceptor of the desired rotation. This form must be completed, signed by both involved preceptors, and submitted to the Director of Experiential Programs at least 30 DAYS PRIOR to the beginning of the rotation in question. Preceptors: You are free to give or withhold permission for a rotation assignment change. Your signature on this form indicates that you have been notified of the change and have given your approval. STUDENT NAME: ROTATION ASSIGNMENT: Site:____________________________________ Date:____________________________________ ROTATION CHANGE: Site: Date:________________________________ Preceptors' Signatures Releasing Preceptor: Date: ______________ Accepting Preceptor: Date: ______________ Please return the completed form to: Director of Experiential Programs NDSU Dept. 2660 118S Sudro Hall, P.O. Box 6050 Fargo ND 58108-6050 Phone: 701-231-5178 Fax: 701-231-7606

DATE: August 14, 2008 TO: Professional Pharmacy Students FROM: Charles D. Peterson, Dean RE: Information Regarding Hepatitis B Vaccine During your experiential training program, you may be exposed to blood and body fluids of patients. Along with this type of exposure is the risk of Hepatitis B infection. This memo is to inform you that there is a vaccine available to protect you against Hepatitis B. The full vaccination against Hepatitis B requires a six-month series of three shots. You can obtain the Hepatitis B vaccine from your doctor, or from the NDSU Student Wellness Center. If you choose to get your immunizations at the Student Wellness Center, appointments are required. You may call 231-5200 to make the necessary arrangements. The decision whether or not to receive the Hepatitis B vaccine is entirely yours. The College of Pharmacy does not require vaccination against Hepatitis B as a requirement for experiential programs. However, the College needs to inform you of the risks involved in being exposed to blood and body fluids of patients and the availability of the vaccine to protect you against Hepatitis B infection. I suggest that you discuss this information with your family doctor so that he/she may assist you in making a decision. Thank you for your cooperation. carol/forms/hepb

WAIVER OF LIABILITY

STUDENT HEPATITIS B DECLINATION FORM The Federal Register, Friday, December 6, 1991 Department of Labor - Occupational Safety and Health Administration, Occupational Exposure to Blood Borne Pathogens: Final Rule states in the Preamble that "Risks among health-care professionals vary during the training and working career of each individual but are often highest during the professional training period. For this reason, when possible, vaccination should be completed during training in schools of medicine, dentistry, nursing, laboratory technology, and other allied health professions before workers have their first contact with blood". I understand that during the course of my experiential training at North Dakota State University College of Pharmacy that I am at risk of exposure to the blood/body fluids of patients. I understand that there is a vaccine available to protect me against Hepatitis B. Please check the appropriate box below: ______ yes, I have received the vaccination against Hepatitis B

date of the third and final injection of the vaccination series _______________

At this time I am voluntarily and knowingly choosing not to be immunized with this vaccine, understanding that not being immunized increases my risk of infection. I release the agencies, namely North Dakota State University and the Experiential Training Site, and their officers and employees, from any liability should I become infectious with Hepatitis B.

______ no, I voluntarily and knowingly choose not to be immunized with the vaccine to protect me against Hepatitis B infection. _____________________________________________ Signature of Student Date _____________________________________________ Print Your Name _____________________________________________ Signature of Dean of College of Pharmacy Date

Carol:forms/hepBfrm2


NORTH DAKOTA STATE BOARD OF PHARMACY

PO Box 1354 Bismarck, ND 58502-1354 Phone: 701-328-9535 Fax: 701-328-9536

Email: [email protected] Website: www.nodakpharmacy.com

AFFIDAVIT OF LICENSED PHARMACISTS/PRECEPTORS

MUST BE LEGIBLY WRITTEN

−

1

was under the following Licensed Pharmacist/Preceptors (Name of Licensed Intern Pharmacist) (Intern No.) for the Experiential Program Rotations approved by the North Dakota State Board of Pharmacy. if on rotation you: Dispense Compound

Community Advanced Practice 200 Hours

Credit


2 Hospital Advanced Practice 200 Hours

Credit


3 Adult Medicine 200 Hours

Credit


4 Rural Community Practice 200 Hours

Credit




Dates 6 (Indicate Elective Rotation) 200 License No.

Hours Credit

Signature of Licensed Pharmacist/Preceptor State License No.

Dates 7 (Indicate Elective Rotation) 200 Hours


Dates



Dates

Total Hours = 1600

THE ABOVE TOTAL HOURS ARE ACCEPTED AND APPROVED BY THE NORTH DAKOTA STATE BOARD OF PHARMACY.

AFFIDAVIT FROM THE DEAN OF THE COLLEGE OF PHARMACY

This is to certify has completed 1600 hours of Full Name of Licensed Intern Intern License Number Experiential Program as required by the North Dakota State Board of Pharmacy Practice Act Laws/Rules and has graduated from North Dakota State University College of Pharmacy, ____________ year curriculum on _________________________________ Graduation Date with a ________________ degree. Dean Subscribed and sworn to before me this day of A.D. Notary Public



PROGRESS REPORT OF LICENSED INTERN PHARMACIST

Progress Report to be completed by Licensed Intern Pharmacist after completion of each experiential rotation. 1. COMMUNITY ADVANCED PRACTICE ROTATION:


2. HOSPITAL ADVANCED PRACTICE ROTATION: a. Briefly describe this experiential rotation: b. Objectives/goals of rotation : SATISFACTORY UNSATISFACTORY NEEDS IMPROVEMENT

3. ADULT MEDICINE EXPERIENTIAL ROTATION:

a. Briefly describe this experiential rotation:

b. Objectives/goals of rotation : SATISFACTORY UNSATISFACTORY NEEDS IMPROVEMENT 4. RURAL COMMUNITY PRACTICE ROTATION:










I ATTEST THAT I COMPLETED EXPERIENTIAL ROTATIONS AS SHOWN ON THE ABOVE PROGRESS REPORT FORM UNDER THE DIRECT SUPERVISION OF THE LICENSED PHARMACIST WHO SIGNED ACCORDINGLY ON THE NOTARIZED AFFIDAVIT (opposite side of this form) IN ACCORDANCE WITH THE LAWS AND RULES OF THE NORTH DAKOTA STATE BOARD OF PHARMACY. Signature of Licensed Intern Pharmacist Intern Number Date

EXAMPLE OF A COVER LETTER FOR YOUR RESUME.

May 1, 2009

Dr. Charles Peterson, Pharm. D. Dean of the College of Pharmacy North Dakota State University Sudro Hall, Room 128 Fargo, ND 58105-5055

Dear Dr. Peterson,

Within the next couple of weeks, I will be working with you to complete Rotation #1. I am looking forward to the opportunity to work in a community setting, as I am seriously considering retail pharmacy as my career path.

Attached to this email, is a copy of my resume which should provide you with some additional information about me. As you read through this resume, please note your likes and dislikes, as I would like to revise my resume with each rotation based on the feedback that I receive from my preceptors. By the end of the year, my resume should be in excellent form for presentation to future employers, following graduation.

I will give you a call within the next week to discuss arrangements for Monday, June 15, 2009.

Sincerely,

Wanda Roden

STUDENT FIELD TRIP INFORMED CONSENT, ASSUMPTION OF RISK AND RELEASE FORM

This document sets out a description of a student field trip (the "Program") and provides for a certification of certain obligations and a release and waiver of liability against North Dakota State University ("NDSU" or "University"). Please read before signing.

1. The Program. I will be spending (Dates) in (Location) with a group of University students and faculty for the following purpose:

2. Travel, Lodging and Meals. Arrangements, including financial responsibilities, for travel, lodging and meals, have been explained to me. Special information is as follows [include if applicable]: 3. Risks of Field Trips. I understand that participation in the Program specified above involves risk not found in normal study at the University. This includes risks involved in traveling to, within and returning from the location. This also includes risks of unique educational activities organized by University or its representatives as part of the Program. I have made my own investigation and am willing to accept these risks.

4. Institutional Arrangements. I understand that the University does not represent or act as an agent for, and cannot control the acts or omissions of, any host institution, host family, transportation carrier, hotel, tour organizer or other provider of goods or services involved in the Program. I understand that the University is not responsible for matters that are beyond its control.

5. Health and Safety.

A. I recognize that I am responsible for my personal medical needs. There are no health-related reasons or problems which restrict my participation in this Program or, if there are, I have informed (Employee) of same and we have agreed upon a reasonable accommodation (attach separate statement in writing). It is my responsibility to notify Employee if there are any medications that I am allergic to or medical treatments I do not want performed.

B. I understand that accident/health insurance is my responsibility. I am covered by health insurance to meet any and all needs or payment of medical costs while I participate in the Program. I recognize that the University is not obligated to attend to any of my medical or medication needs, and I assume all risk and responsibility therefore. If I require medical treatment or hospital care during the Program, the University is not responsible for the cost or quality of such treatment or care.

C. I hereby authorize (Employee), in the event of medical emergency, to authorize emergency medical treatment on my behalf if I am unable to do so or if there is insufficient time to contact members of my immediate family or, if after a reasonable attempt to do so, they are unable to do so. In the event of such medical emergency, I authorize NDSU to contact:

(Name) (Relationship) (Phone) (Address)

6. Standards of Conduct.

A. I understand that as a North Dakota State University student, I will be viewed as a representative of my University. It is my intention to act as a good-will ambassador and conduct myself in a fitting manner. I recognize that behavior which violates laws or University standards could reflect negatively on myself and the University, as well as be adverse to my own health and safety. If I should fall into legal problems while in the Program, I will attend to the matter personally with my own personal funds. NDSU does not guarantee what, if any, assistance it can provide under such circumstances.

B. I also will comply with the laws of the United States and relevant jurisdictions and with the University's rules, standards and instructions for student behavior. I agree to abide by all the rules and regulations of NDSU with regards to my participation in the above activity including, but not limited to, those rules relative to use of alcohol or illegal drugs. I also understand that NDSU can revoke its consent to my participation in this activity at any time for cause or in the event of cancellation of the trip. Should I violate these standards of conduct, I may be sent home at my own expense.

7. Release.

I understand that the University, its employees or agents are not responsible for any injury, loss, damage, delay, irregularity, or expense arising from the use of any common carrier vehicle, accommodations, or services as the result of accidents, strikes, war, weather, sickness, quarantine, governmental restrictions, and other matters beyond the University's power to control. I waive and release all claims against the University and its employees or agents that arise at a time when I am not under the direct supervision of the University or that are caused by my failure to remain under such supervision or to comply with such rules, standards, and instructions.

_________________________Date:________________ Signature of Participant

_________________________ Print Name

Note: While this form was designed for the more significant (and overnight) trips rather than the shorter day or hourly type trip, it can be used for the one-day type trip as well.

COLLEGE OF PHARMACY, NURSING & ALLIED SCIENCES

Request for Sponsored Student Rotation Travel Funds

Student Name: Amount Requested: Rotation Site: Dates of travel: Applicant signature: Date Approval:

Experiential Director Date Approval: Charles D. Peterson, Dean Date Procedure: Request must be submitted prior to travel. After travel, original receipts for the amount requested must be submitted to

the Dean’s Office. Receipts must be specific/itemized and show payment (credit card or cash), not a balance due.

If you have questions, contact Lori Peterson or Julie Bartelson in the Dean’s

Office.

c: Bartelson\forms\student rotation travel 4/4/06


Student Evaluation by Preceptor North Dakota State University Department of Pharmacy

Excellent Average Poor NAStudent Name: Student demonstrated Student demonstrated Student needs DoesPreceptor: excellent skills in this satisfactory skills in improvement in NotRotation Site: area; was extremely area; was generally this area; was ApplyRotation #: effective and/or very effective and/or somewhatMid Evaluation Date (Recommended but not mandatory): consistent.(Could serve consistent. (Appropriate ineffective and/orFinal Evaluation Date: as a role model) for this level.) inconsistent.Section A: Ability Based Outcomes1. Attitudes and Values/ProfessionalismStudent arrives at practice site and meetings on time, meets deadlines for completion of tasks and responsibilities.Student seeks knowledge, asks questions, searches for information, and takes responsibility for his/her ownlearning.Student responds openly and positively to constructive feedback and modifies behavior if necessary.Student demonstrates regard for patients, superiors, colleagues, other personnel, and property.Student demonstrates empathy for patients.Student makes decisions and performs duties in accordance with legal, ethical, social, cultural, economic, andprofessional guidelines.Student adheres to dress code and maintains personal health and good grooming habits as put forth by thepractice setting.

2. Communication SkillsStudent is able to communicate in a caring and respectful manner in all situations using appropriate listening,verbal, nonverbal, and written skills.Student actively and appropriately engages in dialogue or discussion. Not afraid to express his/her viewpoint.Student clearly communicates thoughts, and uses appropriate vocabulary, gestures and mannerisms toconvey information.Student acts and communicates in a self-assured manner, yet with modesty and humility.Identifies and collects all information needed to respond to an information request from anotherhealth care professional using appropriate resources and technology.Responds to an information request from a patient.

3. Scientific FoundationMakes decisions regarding complex problems that require the integration of scientific, social, cultural, and ethical issues with one's ideas and values.Recommends medication doses and dosage schedules for a specific patient based uponrelevant patient factors and drug pharmacodynamic and pharmacokinetic properties.

4. Patient Centered CareStudent establishes relationships with patients, care givers, and other health care professionals asnecessary to provide pharmaceutical care.Evaluates information obtained from the patient's history and physical assessment.Student effectively counsels, communicates, refers and selects the appropriate medications or care plansfor patients.


Patient Centered Care (cont.) Excellent Average Poor NARecommends appropriate drug therapy for a specific patient.Documents information related to the identification, resolution, or prevention of drug-relatedproblems in individual patients.Student effectively retrieves and evaluates medical literature and is able to analyze and apply information indecision making.5. Systems ManagementAccurately select, prepare, and dispense medicaitons in a manner that promotes safe and effective use.Accurately prepare/compound individual or bulk medication in a manner that promotes safe and effective use.Prepare, store, and assure quality of sterile dosage forms.Provide counseling to patients, families, and caregivers.Apply patient and population-specific data, quality assurance strategies, and research processes to optimizepatient outcomes.Section B: Special ProjectsActivity 1: Public Health ProjectCompleted activity was appropriate for the intended audience.Activity and supporting materials were of a professional quality.Demonstrated the ability to follow through with the activity from conception to conclusion.Activity 2:Completed activity was appropriate for the intended audience.Activity and supporting materials were of a professional quality.Demonstrate the ability to follow through with the activity from conception to conclusion.Activity 3: Completed activity was appropriate for the intended audience.Activity and supporting materials were of a professional quality.Demonstrate the ability to follow through with the activity from conception to conclusion.Section C: CommentsComments:

Identify one area in which the student excelled:

Identify one area in which the student could further develop his/her skills:

Signature certifies student completed 200 rotation hours _____________________________________________________Preceptor Signature Date