Leslie Dan Faculty of Pharmacy, University of Toronto
Office of Experiential Education
Advanced Pharmacy Practice Experience (APPE) Program
Non-Direct Patient Care (Elective) Rotation – Application Form
Preceptors/sites wishing to offer an APPE Elective Rotation should complete this form. Please begin by saving this document
on your computer and then type your replies in the shaded boxes. Save and email your completed form to
oee.phm@utoronto.ca or print and fax to: 416-946-3841. This information will help us in determining the suitability of your
site for an APPE Elective Rotation.
PRECEPTOR INFORMATION
Preceptor Name:
Title: Mr.
Ms.
Last:
Miss
Mrs.
First:
Dr.
Date of Application:
Employment Title:
Business phone:
Fax:
Email:
Practice Specialty: (If applicable)
Pharmacy / Other Degree(s) Obtained:
(a) Undergraduate
When
Where
(b) Postgraduate
When
Where
Other Degrees/Diplomas/Certificates:
Site Name:
Store# if applicable:
Site Address:
City:
# Hours worked at this site/week:
Postal Code:
Pharmacist OCP License #:
** If possible, please provide a copy of your CV **
ROTATION INFORMATION
Type of practice (please check one):
☐ Administration/Management ☐ Antimicrobial Stewardship (primarily NDPC)
☐ Consulting
☐ Drug/Medical Information
☐ Drug Utilization Evaluation/Review
☐ Government Services / Regulatory Affairs ☐ Health Technology Assessment
☐ Health economics / Pharmacoeconomics
☐ International / Global Health
☐ Informatics
☐ Investigational Drug Services / Clinical Trials
☐ Leadership / Advocacy ☐ Medication Safety
☐ Professional Associations ☐ Project
☐ Research
☐ Teaching/Education
☐ Other: ___________________________________
September 2014
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Leslie Dan Faculty of Pharmacy, University of Toronto
Office of Experiential Education
Please provide a brief description of the rotation, site, and list activities and contributions you may expect during a
student’s rotation:
Non-Direct Patient Care Rotations
At the beginning of each rotation, students will be expected to establish a learning contract outlining learning objectives for
the rotation and review with their preceptor. The emphasis of non-direct patient care rotations is to enable students to
acquire insight into the structure and functions of various areas of pharmacy practice or the health care system, which may
require different knowledge or skills (e.g. pharmacy administration, policy development, drug utilization review, research,
etc.). The rotation will build on knowledge, skills, and behaviours acquired in earlier academic courses and experiential
rotations. Students will participate in, and take responsibility for acquiring knowledge and skills in the various structure and
functions of pharmacy practice or health care systems. Students will communicate regularly and collaborate with members
of the health care team and/or stakeholders to accomplish the objectives and goals of the rotation. Students are expected to
develop and deliver a presentation during each rotation, on a mutually agreed upon topic, of value to the selected audience.
Each student may complete a maximum of two 5-week non-direct patient care (NDPC) rotations.
Please review the overall learning objectives and outcomes for students in non-patient care rotations:
Introductory = knowledge and comprehension of concepts, definitions,
Intermediate = application of concepts to simple situations
Advanced = application of concepts to more complex situations with ability to synthesize and evaluate
1. Communicator [Advanced]
o Communicate effectively, both in writing and verbally with patients and healthcare providers
2. Collaborator [Advanced]
o Participate in intra- and inter-professional collaboration, serving as an active member of inter-professional
teams
3. Manager [Intermediate]
o Describe and take responsibility for operational, managerial activities
4. Advocate [Advanced]
o Contribute to other professional responsibilities (e.g. committees, policy and guideline development)
o Contribute to patient advocacy by promoting health and wellness and by referring patients to other health
care providers and external agencies
5. Scholar [Advanced]
o Educate students, healthcare providers, and patients
o Participate in near-peer or peer-to-peer teaching models (as applicable)
o Provide care and information using an evidence-informed approach
6. Professional [Advanced]
o Assume legal, ethical and professional responsibilities at all times
o Maintain an updated professional learning portfolio, illustrating self-directed and life-long learning
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Leslie Dan Faculty of Pharmacy, University of Toronto
Office of Experiential Education
Preparation and Commitment for 5- week APPE Rotations
Yes
No
Are you able to commit to scheduling regular meetings with the student (at least 3 hours per week) to
discuss patient care issues, student progress toward learning objectives, and to provide a formal online
midpoint and final assessment for the rotation?
Are you able to commit to a series of required preceptor development modules? (some will be live, some
will be offered online)
I have discussed the APPE Rotation with, and gained support from, my manager to have student(s) on site
and we agree that I will be able to fulfil the role of preceptor.
There will be 10 x 5-week rotation blocks throughout the year: estimate how many student rotations you will be able to offer
each year:
Your Teaching
Effective teaching methods used: (provide specific situations/examples to illustrate)
Engage the student in his/her own learning: (provide specific situations/examples to illustrate)
Number of years you have been a preceptor for pharmacy students in experiential rotations:
Types of students taught (check all that apply): SPEP:
EPE:
Pharm D:
Residents:
Other experiential teaching:
List any non-experiential teaching experience you have (e.g. courses taught):
List any professional development/training you have undertaken to enhance your teaching skills:
Your Interest
What prompted you to apply to become a preceptor for the APPE Rotations?
What value do you perceive this involvement will bring to your practice?
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Leslie Dan Faculty of Pharmacy, University of Toronto
Office of Experiential Education
Provide any other information or comments pertinent to your application.
(e.g. CV, publications, presentations, awards, etc.)
Please save/make a copy for your records and then send the completed form to: oee.phm@utoronto.ca or print and
fax to: 416-946-3841. This information will help us in determining the suitability of your site for the APPE Elective
Rotations.
A faculty Experiential Education Coordinator will review your application and contact you for further information if necessary.
Thank you for your interest in participating in the APPE Elective Rotations!
Faculty use only:
Date received:
Coordinator initials:
Comments/issues to clarify:
OCP License verification:
September 2014
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