Introductory Pharmacy Practice Experience (IPPE) Forms

IPPE Program Overview
Use the following link to view a description of our IPPE program, requirements, competency check lists and evaluation forms. All forms listed in this section are available in this booklet.
Early Experience Manual 2010 (PDF)

IPPE Preceptor Application
All preceptors must complete the following form the first time he or she precepts a UF student (either by using the web-based version or by printing and returning via fax or mail to the Director of Experiential Education).   
IPPE Preceptor Application (PDF)

Experiential Competency Checklist
Students taking part in experiential education at The University of Findlay are required to complete tasks that demonstrate their competency in certain areas. Preceptors should use this form to check off each competency as it is met.
P3 Experiential Competency Checklist (PDF)
P4 Experiential Competency Checklist (PDF)
P5 Experiential Competency Checklist (PDF)

Preceptor Evaluation
Following a student's participation in experiential education, preceptors should use this form to evaluate the student's abilities.
Preceptor Evaluation of Student (PDF)

Student Evaluation
Students taking part in experiential education should fill out a preceptor evaluation form after completing the experience. Students should fill out one form for each preceptor they have.
Student Evaluation of Preceptor (PDF)

Mentor Evaluation
This evaluation page allows students to rate their pharmacist mentors. This form is needed for successful completion of the PHAR 350 and PHAR 351 courses.
Pharmacist Mentor Review (PDF)

Community Service
For each student in the College of Pharmacy, community service experience is required. Twenty hours of service must be completed during the P3-P5 years to satisfy the requirements of PHAR 591.
Community Service Form - 20 Hours (PDF)

Introductory Experience Affidavit
This form is used to track experiential education completed by each student. The affidavit should be completed once per year and turned in by the corresponding electronic portfolio due date.
IPPE Affidavit


Advanced Pharmacy Practice Experience (APPE) Forms

APPE Program Overview
Use the following link to view a description of our APPE program, requirements, policies and evaluation forms. All forms listed in this section are available in this booklet.
Full Manual APPE


Student Evaluation Form
The preceptor is to complete the “First Evaluation” section of this form during the middle week of the rotation.  The “Final Evaluation” section and final grade should be completed during the last week of the rotation.  During the First and Final Evaluations of the student, the preceptor will discuss the student’s strengths and weaknesses.  Although First and Final Evaluations are required, only the Final Evaluation will be used in determining the student’s grade for the rotation. The Final Evaluation should indicate the student’s level of competence upon completion of the rotation.  The preceptor will also keep a copy on file.  The original form must be mailed or may be submitted electronically via the RxPreceptor webiste to the Director of Experiential Programs on the last day of the rotation.
PharmD Student Rotation Evaluation Form (PDF)

Student Self-Assessment Form
The student must complete a self-evaluation at the end of each rotation.  The completed evaluation will be included as part of the Professional Portfolio.  This evaluation should be discussed with the preceptor prior to the completion of the rotation. 
Student Self Assessment Form (PDF)

Longitudinal Outcome Measures Assessment Form
During the Advanced Practice Rotations, the student must complete all longitudinal outcome measures.  Upon completion of each outcome measure, the preceptor or Hub Site Coordinator shall evaluate the student’s performance.  The preceptor should discuss the evaluation with the student.  The student must include the original assessment form with the professional portfolio (RxPortfolio) at the end of the rotation sequence.  Each student is responsible for completing all activities listed on this form.
Longitudinal Outcome Measures Assessment Form (PDF)

Journal Club Evaluation Form
Many rotation sites require the student to give a verbal journal club presentation.  This is a representative copy of the evaluation form the preceptor may choose to utilize.  This form is NOT a required form.  However, if this form is completed by the preceptor, it should be included as part of the Professional Portfolio (RxPortfolio). 
Student Journal Club Evaluations (PDF)

Preceptor Evaluation Form
The student should use this form at the end of the month to evaluate the rotation site or he or she may use the RxPreceptor website to submit an electronic copy. The original form, if used, should be sent to the Director of Experiential Programs. 
Preceptor Evaluation Form (PDF)
 
Case Presentation Evaluation Form
Many rotation sites require the student to give verbal case presentations.  This is a representative copy of the evaluation form the preceptor may choose to utilize.  This form is NOT a required form.  However, if this form is completed by the preceptor, it should be included as part of the Professional Portfolio (RxPortfolio).
Case Presentation Evaluation Form (PDF)

Patient Communication Evaluation Form
Each student must complete ONE (1) Patient Communication Evaluation during the rotation sequence.  The preceptor may enact the part of the patient, may assign another colleague to enact the part of the patient, or assign a real patient for the student to interact with.   The student should be observed and evaluated based upon the criteria provided on the Patient Communication Evaluation Form.  This form should be submitted as part of the Professional Portfolio (RxPortfolio) at the completion of the rotation sequence.
Patient Communication Evaluation Form (PDF)
 
Absence Request Form
Each student should use the Absence Request Form to request approval for time off during a rotation.
Absence Request Form (PDF)


Other Helpful Links

Ohio State Board of Pharmacy
RxPortfolios
RxPreceptor