Leslie Dan Faculty of Pharmacy, University of Toronto
Office of Experiential Education
Community Direct Patient Care - Advanced Pharmacy Practice Experience Program (APPE)
Application Form
Please begin by saving this document on your computer and then type your replies in the shaded boxes. Save your
completed form. Email completed form to oee.phm@utoronto.ca or print and fax to: 416-946-3841
Pharmacy preceptors/sites wishing to participate in Community Direct Patient Care APPE rotations should complete
this form.
Pharmacist’s Name:
Title: Mr.
Ms.
Last:
Miss
First:
Mrs.
Business phone:
Dr.
Date of application:
Employment Title:
Fax:
Email:
Practice Specialty/Primary Practice Area: (If applicable)
Number of years practicing in community pharmacy:
Pharmacy Degree(s) Obtained:
(a) Undergraduate
When
Where
(b) Postgraduate qualification
When
Where
Additional Degrees/Diplomas/Certificates:
# Hours worked at this site/week:
Pharmacist OCP License #:
Pharmacy Name:
Store number:
Site Address:
City:
Postal Code:
Type of practice (please choose one): (a) Community Pharmacy Chain
(b) Community Pharmacy Banner
(c) Community Pharmacy Independent
(d) Other: Please specify
Manager’s Name: Last:
First:
Manager’s Email:
Manager’s Phone:
Title: Mr.
Ms.
Miss
Mr.
Dr.
Fax:
PRECEPTOR INFORMATION:
1. Your Practice ( Please provide specific situations/examples that illustrate how you meet the following criteria)
Implemented expanded scopes of practice
Motivated and inspired pharmacists to develop patient care services
Demonstrated patient care problem solving skills
May 2013
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Leslie Dan Faculty of Pharmacy, University of Toronto
Office of Experiential Education
Self motivated to remain current in practice
2. Preparation for APPE
Yes
No
Are you able to commit to regular meetings with the student (at least 3 hours per week) to discuss
student activities/progress/learning objectives, and to provide a formal written midpoint and final
assessment for the rotation?
Are you able to commit to a series of required preceptor development modules?
I have discussed the APPE 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
Are you able to commit to precepting students for 10 out of 12 months/year? (i.e. 8 x 5 week rotation
blocks/year)
3. Your Teaching ( Please provide specific situations/examples that illustrate how you meet the following criteria)
Demonstrates effective teaching methods
Able to develop students to their maximum potential
Able to engage the student in his/her own learning
Yes
No
Have you previously precepted pharmacy students?
Number of years precepting pharmacy students
List previous teaching experience(s) including courses taught, or training you have undertaken (may be pharmacy or
non-pharmacy related):
4. Your Interest
What prompted you to apply to become a preceptor for APPE rotations?
What value do you perceive this involvement will bring to your practice?
SITE INFORMATION (Please fill SITE INFORMATION only once per site)
Site information is provided on (name of preceptor’s)
application
1. Site Description
Indicate patient population: 1. Paediatric %
2. Geriatric %
3. General adult %
4. Other %
Staffing:
Please describe:
Pharmacist FTE
Total Technician FTE
Number of Registered Technicians
May 2013
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Leslie Dan Faculty of Pharmacy, University of Toronto
Office of Experiential Education
Describe how the staffing structure supports patient care (include description of roles for both pharmacist and
technician)
Average number of prescriptions per day
Average number of patients seen per day
Please describe any automation used by the pharmacy (ie. Robotics, baker cells, scanning barcodes)
Number of years site has precepted/trained dispensary staff (please include all team members including pharmacy
students/interns, assistants and registered technicians)
Yes
No
Yes
No
Does the site commit to accepting students for 10 out of 12 months each year?
Which months of the year is the site not available for precepting APPE students?
2. Pharmacy Practice
Do pharmacist(s) collaboratively work with other health care professionals, participating as an
active member of patient care teams?
If YES, please describe:
Are staff pharmacist(s) certified to provide influenza immunizations?
Other services provided:
Specialty compounding
Nursing home consultations
Compliance packaging
Home health care
IV services
3. Pharmacy Clinics ( Please select all that apply and provide date of last clinic in each category)
Yes
Allergies
Anticoagulation
Arthritis
Asthma
BPH
CHF
Diabetes
Dyslipidemia
Geriatrics
Hypertension
Metabolic Syndrome
Osteoporosis
Smoking Cessation
Weight loss
Women’s Health
Vision Care
May 2013
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No
Leslie Dan Faculty of Pharmacy, University of Toronto
Office of Experiential Education
Other: please list
Describe any services that are unique to your pharmacy (that have not been discussed above)
4. Expanded Scopes of Practice
Average number of weekly WALK-IN MedsChecks
Average number of weekly SCHEDULED MedsChecks
Average number of weekly REFFERAL MedsChecks
Average number of weekly HOME VISIT MedsChecks
Average number of times pharmacist renews and/or adapts (alter dose, dosage form, regimen, or route of
administration) prescriptions/week
Average number of times pharmacist prescribes drug products for purpose of smoking cessation/week
Average number of times pharmacist performs a procedure on tissue below the dermis to support patient self-care
and chronic disease monitoring /week
Average number of times pharmacist administers, by injection or inhalation for the purposes of education and
demonstration/week
Provide any other information or comments pertinent to your application.
Please save/make a copy for your records and then send the completed form to:
oee.phm@utoronto.ca or fax: 416-946-3841
Thank you for completing this application form. This information will help us in determining the suitability of your site for the
Community APPE rotations.
A faculty Experiential Education Coordinator will review this application and contact you for further information if necessary.
Thank you for your interest in participating in the Community Direct Patient Care APPE!
Faculty use only:
Date received:
Coordinator initials:
Comments/issues to clarify:
OCP License verification:
Site approval: YES
May 2013
NO
Preceptor approval:
YES
NO
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