Advanced Professional Practice Experience Preceptor Application Form

Pharmacy preceptors wishing to become preceptors for the PharmD students should fill out this form and submit it online.

Part I

PRECEPTOR INFORMATION

Pharmacist’s Name: First: Required Last: Required
Title: Employment Title:
Phone number: Required Email: Required

Pharmacy Degree(s) Obtained**:
(a) Undergraduate When Where
(b) Postgraduate qualification When Where
Additional Degrees/Diplomas/Certificates:
Years of Practice: Years In Kuwait Years Outside Kuwait (please specify)
Workplace:
# Hours worked at this site/week:

** If possible, please provide a copy of your degree certificates and CV **

ROTATION INFORMATION

Specify the type of clinical practice service(s) that you are currently providing (please check all applicable):
Acute care (ER) Ambulatory Medicine Surgery
Critical Care (ICU, CCU) Geriatrics Paediatrics Psychiatry
Other

Specify the type of Non-Direct Patient Care service(s) that you are currently providing (please check all applicable):
Quality Control CMS Drug Inspection
Other

Preparation and Commitment for 7- week Rotations
Are you able to meet regularly with the student to discuss patient care issues, student progress toward learning objectives, and to provide a formal midpoint (evaluation halfway through the rotation) and final assessment for the rotation?	Yes No
Are you able to commit to a series of required preceptor training workshops?	Yes No

Part II

Preceptor Personal Statement

What are your personal beliefs and attitude towards pharmacy practice? (please limit to 3-4 sentences) (The statement may include any information regarding the knowledge, skills and positions responsibility you have obtained through your work that might be relevant to providing pharmaceutical care to patients.)

Please describe in a few words the services that you personally provide to every patient you care for.

What personal qualities and skills do you possess and use when providing the above service(s) to patients?

In general, what are the aims and objectives of your communication with your patients?

Provision of Pharmaceutical Care

What actions do you take to identify, prevent and resolve actual and potential drug-related problems for your patients?

Collaboration with physicians and other health care providers is necessary to address some medication-related issues. What techniques do you use to ensure that your interactions with physicians are effective and result in positive outcomes for patients?

Describe any changes that you have initiated to increase patient focus in your individual practice and to strengthen the profession's focus on direct patient care?

Drug and therapy information resources

Do you have access to the necessary resources? Please elaborate.

What role does technology play to support your individual patient-focused practice (e.g. Pharmacy Information System, Electronic Health Records, Automated Dispensing Machines, etc…)?

Teaching Experience

List previous teaching experience(s). (may be pharmacy or non-pharmacy related)

Indicate any specific training/ continuing education you have received, or have provided to others, related to the pharmaceutical care model of practice. (e.g. through undergraduate curriculum, seminars, in-service/in-house workshops/staff orientation) (State approximate number of hours if workshop or seminar).

Your Interest

What prompted you to apply to become a preceptor for the Rotations?

What value do you perceive this involvement will bring to your practice?

Please feel free to provide any other information or comments relevant to your application and/or related to your practice. (E.g. publications, presentations, awards, etc.)

I certify that the above information is correct to the best of my knowledge.

Thank you for your interest!