Ministry of Higher Education College of Pharmacy

Kingdom of Saudi Arabia Jazan University

Ministry of Higher Education College of Pharmacy

Department of Clinical Pharmacy

Clinical Training Unit

Internship Evaluation Form

Drug and Poison Information Center (DPIC)

Student name:…………………………………………………………………………………

Student ID:…………………………………………………………………………………

Rotation name:………………………………………………………………………………..

Rotation code:………………………………………………………………………………….

Location:……………………………………………………………………………………….

Training period: From / / 20 to / /20

Kingdom of Saudi Arabia Jazan University

Ministry of Higher Education College of Pharmacy

Department of Clinical Pharmacy

Clinical Training Unit

Internship Evaluation Form

Drug and Poison Information Center (DPIC)

General Guidelines for Preceptor

Kindly please read the following instructions:

The evaluation form is a confidential document; accordingly, the contents should not be shared with anyone including the intern.

Continuous feedback to the intern is recommended in order to fill the gaps and to strengthen the weak points that are observed during the training period.

Please make sure that the attendance form is signed by both preceptor and intern.

Please make sure that the portfolio of the intern is appropriately completed during the training period.

If the intern is fails in the personal and ethical evaluation part, this will be considered as an overall failure irrespective of the degree that has been awarded in the other skills; consequently, the intern shall repeat the concerned rotation for full duration.

Please make sure that the evaluation form together with the attendance form, in addition to the assignments and completed pharmaceutical care patient record forms are enclosed in a properly sealed and stamped envelope after evaluation.

Your participation and great efforts are highly valued and appreciated by the College of Pharmacy-Jazan University.

Jazan University Kingdom of Saudi Arabia

Ministry of Higher Education College of Pharmacy

Department of Clinical Pharmacy

Clinical Training Unit

Internship Evaluation Form

Drug and Poison Information Center (DPIC)

Personal and ethical evaluation:

Total mark is 40

Parameter / Marks / Comments
Attendance
(out of 10)
Punctuality
(out of 10)
Professionalism
(out of 10)
Attitude / With healthcare professionals
(out of 5)
With requestor
(out of 5)

Final mark for the personal and ethical evaluation: /40

Other skills evaluation: (Total marks is 60 divided as the following)

Activity / Score / comments
1-Understanding of DIC literatures and searching processes and appropriate use of drug information resources / …../ 2.5
2-Providing drug information responses at the proper time and in a suitable format, i.e. responses should have: an introduction, findings from the literature and intern recommendations or conclusions / ……./5
3-Performance during stay in DIC receiving and preparing the answers to the daily inquiries / ……/ 5
4-Performance and discussion during delivering the answer to the health care provider or to a lay person. / …../ 2.5
5-Maintaining a well-organized portfolio and assuring patient privacy and confidentiality in all drug information activities. / ……./ 5
6-Preparing at least five of the following:
-3-5 drug information responses daily
-Attending and reporting one pharmacy related meeting e.g. pharmacy and therapeutic committee P&T, Infection control, Quality assurance..etc. (If applicable)
-Two adverse drug event reports
-Two medication error reports
-One formulary drug monograph
-One journal club
-One evidence-based practice guideline review
-One patient education material
-One pharmacoeconomic analysis report
-Present a project as a poster at a meeting / ….../ 40

Final mark for part (B) : /60

Total mark: /100

Any additional comments:

………………………………………………………………………………………………

Preceptor name:…………………………………………………………………………..

Specialty:………………………………………………………………………………….

Signature:…………………………………………………………………………………..

Stamp:………………………………………………………………………………………

Date:………………………………………………………………………………………..

Kingdom of Saudi Arabia Jazan University

Ministry of Higher Education College of Pharmacy

Department of Clinical Pharmacy

Internship Evaluation Form

Drug and Poison Information Center (DPIC)

ATTENDANCE FORM

Student name: ID number:

Rotation name and code: Location:

Day / Date / Student's signature / Preceptor signature