Pharmacy Continuing Education
Technician w/Pharmacists Application Form
Single Program
This form is to be used in conjunction with Pharmacy credit Application for Single programs only. Please
also fill out the document titled SessionInfo_template.doc for details on each session. Separate
information is needed for Technicians; this should be different than what is submitted for pharmacists.
We no longer give credit for an entire day of events.
INSTRUCTIONS:
Please submit additional form along with Pharmacists application and Session Information as soon as you
have a completed Agenda. Additional information can be found on the Pharmacist application form.
Email this application and any supporting documents to Christina Muñoz, Continuing Pharmacy Education
Administrator at cmunoz@salud.unm.edu (505-272-3125).
I. Program Details
A. Program Title affiliated with:
B. Number of continuing education hours requested for Pharmacy Technicians:
(60 minute live program is equal to 1.0 CE hour – lunch and breaks should not be included)
C. Topic Designator (only select 1):
01: Drug Therapy Related - Covers all programs that address drugs, drug therapy, and/or disease states.
02: AIDS Therapy Related - Covers all programs that address therapeutic, legal, social,, ethical, or
psychological issues related to the understanding and treatment of patients with AIDS.
03: Law - Covers all programs that address federal, state, or local laws and/or regulations affecting the
practice of pharmacy.
04: General Pharmacy Topics - Covers all programs that address topics relevant to the practice of
pharmacy other than those included in the classifications of drug therapy related, AIDS therapy related, and
law.
05: Patient Safety - The prevention of healthcare errors, and the elimination or mitigation of patient
injury caused by healthcare errors (An unintended healthcare outcome caused by a defect in the delivery of
care to a patient.) Healthcare errors may be errors of commission (doing the wrong thing), omission (not
doing the right thing), or execution (doing the right thing incorrectly). Errors may be made by any member
of the healthcare team in any healthcare setting. (definitions approved by the National Patient Safety
Foundation® Board July 2003)
II. Planning and Development
A. How were educational need(s) identified specifically for Pharmacy Technicians?
Target audience survey
Consensus of experts
Training deficit
New policy/regulation/procedure/technique
Other:
Previous evaluations
B. How will this activity or program fulfill the identified need?
CPE Pharmacy/Technician Request Form (Single event)
Revised: February 2015
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C. Learning Objectives (3 Per program required): List statements that reflect what each participant will
earn from attending/participating in this program or activity specifically for technicians. At the conclusion of
this program, the participant will be to:
D. Instructional Method: Mark all that apply.
Lecture
Monograph
Practice Session
Other:
Case Study
Panel discussion
Demonstration and practice
F. How will the selected instructional method(s) contribute to the learning objectives?
G. Attach a copy of the program outline/abstract or handouts of the content to be presented.
H. Delivery Method:
Computer based instruction (CD based)
Live, instructor led
Other
I. Type of Activity (check only one):
Activity
Knowledge (minimum 15 minutes)
Application (minimum 60 minutes)
Practice (minimum 15 hours)
Web-based instruction
Self-study
Hybrid (lecture and web-based)
Activity Purpose
Transit Knowledge
Apply Information
Instill knowledge,
skills, attitudes
LearningAssessment
Questions/Recall of Facts
Case studies/application of principles
Formative and summative
J. List of Speakers/Instructors and anyone directly involved with creating program content specific to
Technicians
Full Name(s)
Email address’
III. Active Learning, Assessment and Evaluation
A. What Active Learning strategies will be used? (Select all techniques used)
Group discussion
Round Table
Case study/Scenarios
Problem Solving
Role Playing
Active questioning
Lecture with Q&A
Audience response system (iClicker)
Application exercise
Other:
B. How will the learners assess their achievement of the desired learning objectives?
Pre & post test
Post test only
Group discussion
Case study
Other:
Follow up survey
C. How will the learner evaluate the quality of the program?
Follow up survey
Group discussion Other:
IV. Advertisement
CPE Pharmacy/Technician Request Form (Single event)
Revised: February 2015
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What sort of advertisement will be issued?
(Brochure, Flier, Internet etc.) Attach if already created,
must indicate the audience includes Pharmacy Technicians. Specific wording is required on advertisements
and will be sent to you upon approval of CE program.
V. Statement of Credit
Certificates will no longer be issued, all CPE including pharmacy technician credit will be submitted through
CPE Monitor immediately using our online program. NABP ePID and MM/DD is required, no exceptions
VI. Faculty
A. Will off-label use be discussed? Yes
No
if no skip section
B. What methods of off-label disclosure will be used?
On printed material
Announced at program beginning
Other:
VII. Accreditation Action
A. Date submitted for review:
B. Recommended for
contact hours of continuing pharmacy education (Pharmacy Technicians)
By: ____________________________________________________ (electronic confirmation is accepted)
Program Organizer Signature
VII. Accreditation Approval
Approved for
contact hours of pharmacy continuing education (CPE)
Not approved for pharmacy continuing education credits for the following reasons
By: ____________________________________________________
_________________
CPE Director
Date
Universal Program Number assigned:
Expiration Date:
By: ____________________________________________________
___________________
CPE Administrator
Date:
CPE Pharmacy/Technician Request Form (Single event)
Revised: February 2015
Page 3 of 3