Site Name:____________________________ City:____________________
Preceptor Name(s):________________________________________________________________________
Rotation:_____________________________________________________________________________________
| This Evaluation Must Be
Completed Before Grades Are Forwarded To The Register's Office |
During this rotation you were given the opportunity to learn to apply your knowledge and skills in the areas listed below. Insert the number best representing your level of agreement or disagreement for each of the areas according to the following scale:
| Strongly Agree | Agree | Neutral | Disagree | Strongly Disagree | Not Applicable |
| 5 | 4 | 3 | 2 | 1 | N/A |
| Area Evaluated | Rating |
| 1. Apply your pharmaceutical knowledge to actual
patients. |
|
| 2. Communicate with medical students. | |
| 3. Communicate with medical residents and interns. |
|
| 4. Communicate with attending physicians. | |
| 5. Communicate with nurses. | |
| 6. Recognize patient problems. | |
| 7. Obtain a medication history. | |
| 8. Define therapeutic goals or end points for a problem. | |
| 9. Compare and identify the most appropriate treatment modality for a problem. | |
| 10. Recommend the most appropriate therapeutic drug
regimen for a patient. |
|
| 11. Provide patient medication counseling. | |
| 12. Use drug information skills applicable to patient care. | |
| 13. Monitor, observe or detect the effects of drug therapy such as: | |
| a. Drug effectiveness. | |
| b. Drug toxicity | |
| c. Adverse drug reactions. | |
| d. Drug interactons |
Place the number best representing your level of agreement (according to the rating scheme immediately below) in the column to the right of each statement related to instructor evaluation.
| Strongly Agree | Agree | Neutral | Disagree | Strongly Disagree | Not Applicable |
| 5 | 4 | 3 | 2 | 1 | N/A |
| Area Evaluation | Rating |
| 14. The instructor was knowledgeable in the subject matter. | |
| 15. The instructor was enthusiastic about the rotation. | |
| 16. The instructor was willing to give individual help. | |
| 17. The instructor was impartial in dealing with students. | |
| 18. The instructor treated you with respect. | |
| 19. The instructor showed tolerance with different points of view. | |
| 20. The instructor was prompt in meeting the students and keeping appointments. | |
| 21. The instructor required high standards of performance by the students. | |
| 22. The instructor was able to communicate the subject matter effectively to students. | |
| 23. The relationships between the instructor and students facilitated student learning. | |
| 24. The instructor served as an effective role model for the type of pharmacy practice that you want to emulate. | |
| 25. Exam material was fair and test what you learned during the rotation |
26. On average, how much direct interaction in hours, e.g., one-on-one and/or group meetings did you have with your preceptor each day or each week? Explain:_______________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
27. Overall, how would you rate your instructor as an effective teacher? Please indicate your rating by checking the appropriate box below:
a. Very Effective __________
b. Moderately Effective __________
c. Slightly Effective __________
d. Not Effective At All __________
Using the numbers corresponding to the rating in the table immediately below, indicate how you felt regarding the adequacy of the site in each of the listed areas:
| Strongly Agree | Agree | Neutral | Disagree | Strongly Disagree | Not Applicable |
| 5 | 4 | 3 | 2 | 1 | N/A |
| Area Evaluated | Rating |
| 28. Drug information resources. |
|
| 29. Space. | |
| 30. Computer facilities. | |
| 31. Parking. | |
| 32. Pharmaceutical care activities. |
33. Overall, how would you rate the practice site? Please indicate your rating by checking the appropriate box below:
a. Excellent __________
b. Above Average __________
c. Adequate __________
d. Some Deficiencies __________
e. Inadequate __________
34. Are there any changes which could be made that would have enabled you to gain more from this rotation?
35. What aspect(s) of this rotation did you like MOST? Why?
36. What aspect(s) of this rotation would you change? Why?
37. Additional comments:
| Once You Have Completed This Form, Seal It in the Envelope Provided and Give It to Your Preceptor on the Last Day of the Rotation. This Form Will Be Shared With Your Preceptor AFTER Your Grade Has Been Received in the Department of Pharmacy Practice and After It Has Been Reviewed by Dr. Swanson and the Director of Experiential Programs |
| This Evaluation Must Be
Completed Before Grades Are Forwarded To The Register's Office |