Forms

PY4, Class of 2010

Forms

► Competency Check Sheet (Appendix 2, pages 22-25 from the APPE Manual & Global Syllabus).

► Mid-Rotation Evaluation Form

► Patient Encounter Data Collection Form

►Midyear Evaluation Follow-up Form. This form is used to identify areas needing improvement or lacking exposure from the Midyear Evaluation form. This form must be turned in at the completion of rotations with the summary competency check sheet and the Midyear review.

► Kentucky Board of Pharmacy (KBP) Practical Experience Affidavit Form

► Evaluation of UK Medical Center (UKMC) Pharmacy Resident on Service. PY4 Pharm.D. students assigned a UKMC rotation with a resident are asked to complete an evaluation form for that resident. The only resident evaluation that is to be completed is located through the CoursEval site (http://128.163.99.31/etw/ets/et.asp?nxappid=WCQ&nxmid=start).

►Area Health Education Center (AHEC) Student Forms Link

AHEC Fact Sheet: PDF & Word Format

Off-Site Rotation Assessment Form

Rent Receipt Form

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