preceptor progress report - oklahoma · internpr dec-13 oklahoma state board of pharmacy 2920 n...

internpr Dec-13 OKLAHOMA STATE BOARD OF PHARMACY 2920 N Lincoln Blvd, Ste A, Oklahoma City, OK 73105 Phone: (405) 521-3815 / Fax: (405) 521-3758 www.pharmacy.ok.gov e-mail: [email protected] PRECEPTOR'S INTERN PROGRESS REPORT Intern Name Intern No. Training Area # - (pharmacy license no.) TA Address Report period: / / to / / for Non-college practice hours (date) (date) (total) Is this intern currently pursuing a Pharm.D. degree? .................................................... Yes No This report ends employment at this training area .......................................................... Yes No My evaluation of this intern is A=Excellent, B=Above Average, C=Average, D=Below Average (circle one): 1. Ability to meet people A B C D 2. Ability to cooperate A B C D 3. Ability to work with others A B C D 4. Attitude toward fellow employees A B C D 5. Attitude toward patients A B C D 6. Attitude toward preceptor A B C D 7. Attitude toward other pharmacists A B C D 8. Personal self-confidence A B C D 9. Personal self-discipline A B C D 10. Personal hygiene A B C D 11. Character A B C D 12. Ability to comprehend A B C D 13. Ability to be instructed A B C D 14. Interest in profession A B C D 15. Interest in allied professions A B C D 16. Interest in patients A B C D 17. Accuracy A B C D 18. Pharmacy knowledge A B C D 19. Ability to apply knowledge A B C D 20. Professionalism A B C D AN INTERN RECEIVING FIVE OR MORE D'S MAY LOSE CREDIT FOR THESE HOURS. What is your professional opinion of this intern as a future pharmacist? (Use the reverse side for any additional comments.) This is my evaluation of the stated intern. I have followed Board regulations and state that this report is true and correct. Signed upon my honor. Print Preceptor Name & Cert. # Preceptor Signature Date

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internpr Dec-13

OKLAHOMA STATE BOARD OF PHARMACY 2920 N Lincoln Blvd, Ste A, Oklahoma City, OK 73105 Phone: (405) 521-3815 / Fax: (405) 521-3758 www.pharmacy.ok.gov e-mail: [email protected]

PRECEPTOR'S INTERN PROGRESS REPORT

Intern Name Intern No. Training Area # - (pharmacy license no.)

TA Address

Report period: / / to / / for Non-college practice hours (date) (date) (total)

Is this intern currently pursuing a Pharm.D. degree? .................................................... Yes No

This report ends employment at this training area .......................................................... Yes No My evaluation of this intern is A=Excellent, B=Above Average, C=Average, D=Below Average (circle one): 1. Ability to meet people A B C D 2. Ability to cooperate A B C D 3. Ability to work with others A B C D 4. Attitude toward fellow employees A B C D 5. Attitude toward patients A B C D 6. Attitude toward preceptor A B C D 7. Attitude toward other pharmacists A B C D 8. Personal self-confidence A B C D 9. Personal self-discipline A B C D 10. Personal hygiene A B C D

11. Character A B C D 12. Ability to comprehend A B C D 13. Ability to be instructed A B C D 14. Interest in profession A B C D 15. Interest in allied professions A B C D 16. Interest in patients A B C D 17. Accuracy A B C D 18. Pharmacy knowledge A B C D 19. Ability to apply knowledge A B C D 20. Professionalism A B C D

AN INTERN RECEIVING FIVE OR MORE D'S MAY LOSE CREDIT FOR THESE HOURS. What is your professional opinion of this intern as a future pharmacist? (Use the reverse side for any additional comments.) This is my evaluation of the stated intern. I have followed Board regulations and state that this report is true and correct. Signed upon my honor. Print Preceptor Name & Cert. # Preceptor Signature Date

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Volume 20 Number 18 July 15, 2003 Pages 2635 - 2682 The ... · Oklahoma City, OK 73152-3390, or by calling (405) 521-4911 or faxing (405) 522-3555. Office hours are 8:00 a.m. to 5:00

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Oklahoma(Educa-on(Dashboards((OKED ......Oklahoma State Department of Education | 2500 N. Lincoln Blvd, Oklahoma City, OK 73105 | T 405-521-3301 | www .ok.gov/sde Oklahoma(Educa-on(Dashboards((OKED):(

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