Leslie Dan Faculty of Pharmacy, University of Toronto
Office of Experiential Education
Advanced Pharmacy Practice Experience (APPE) Program
Direct Patient Care Rotation – Application Form
Pharmacy preceptors/sites wishing to offer an APPE Direct Patient Care 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 practice site for an APPE Rotation.
PRECEPTOR INFORMATION
Pharmacist’s Name:
Title: Mr.
Ms.
Last:
Miss
First:
Mrs.
Dr.
Business phone:
Date of Application:
Employment Title:
Fax:
Email:
Pharmacy Practice Specialty:(If applicable)
Pharmacy Degree(s) Obtained:
(a) Undergraduate
When
(b) Postgraduate qualification
Where
When
Where
Additional 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 all applicable):
☐ Acute care ☐ Ambulatory
☐ Community ☐ Family Health Team
☐ Chronic Care ☐ Geriatrics
☐ Paediatrics
☐ Rehabilitation
☐ Psychiatry
☐ Other: ___________________________________
SPECIALIZED SERVICES (check all those that apply):
☐ Anticoagulation ☐ Diabetes ☐ Nutrition Support (TPN) ☐ Oncology ☐ Palliative Care
☐ Antimicrobial Stewardship
☐ HIV
☐ Infectious Disease
☐ Cardiology ☐ ER/Trauma ☐ NICU/MICU/SICU
☐ Nephrology ☐ Neurology
☐ Transplant
☐ Other:_______________________________________________________________________
September 2014
Page 1 of 4
Leslie Dan Faculty of Pharmacy, University of Toronto
Office of Experiential Education
Please provide a brief description of the rotation, site, and any unique patient care issues/contributions you may
expect during a student’s rotation:
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 direct patient care rotations is primarily on the provision of
pharmaceutical care. Students will participate in, and take responsibility for, direct patient care activities including: patient
assessment to identify and prioritize drug therapy problems, development of care plans that address desired patient
outcomes, and patient monitoring including physical and laboratory assessment, and where feasible, carry out a follow-up
evaluation and appropriate documentation. Students will communicate regularly with patients and care givers to monitor
patient parameters, determine and assess target outcomes, and provide education. The collaboration with other health
care disciplines and acting as a member of a patient care team will be vital in providing optimum patient care. Students will
work closely with members of the health care team in providing collaborative care; with regular communication with team
members to share and document their assessment of the patient’s medication related needs and recommendations to
address those needs. Students are expected to develop and deliver a presentation during each rotation, on a mutually
agreed upon topic, of value to the selected audience. In community pharmacy rotations, students will manage accurate and
effective drug distribution under the supervision of the pharmacist and will be expected to participate in expanded scopes of
pharmacy practice.
Please review the overall learning objectives and outcomes for students in direct 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. Care Provider [Advanced]
o Provide pharmaceutical care
o Demonstrate capabilities in the full scopes of practice that are practiced at the specific site
2. Communicator [Advanced]
o Communicate effectively, both in writing and verbally with patients and healthcare providers
3. Collaborator [Advanced]
o Participate in intra- and inter-professional collaboration, serving as an active member of patient care teams
4. Manager [Intermediate]
o Describe and take responsibility for operational, managerial and/or distribution activities
5. 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
6. 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
7. 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
September 2014
Page 2 of 4
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?
September 2014
Page 3 of 4
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 practice for the APPE
Rotation.
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 Rotations!
Faculty use only:
Date received:
Coordinator initials:
Comments/issues to clarify:
September 2014
Page 4 of 4