Preceptor/Site Approval Form for Practice …

1 Preceptor/Site Approval form for Practice experience within nova scotia It is the responsibility of the Student/Intern to ensure that this form reaches the College office prior to the commencement of Practice experience with the preceptor named below. Unstructured time service must be completed at a minimum of 25 hours per week up to a maximum of 40 hours per week, in a direct patient care setting. Students/Interns MUST BE REGISTERED with the nova scotia College of Pharmacists, as Registered Students or Interns, before commencing Practice experience in a pharmacy and must be registered for the duration of the Practice experience period. A separate Registration form must be used for this purpose. Preceptor Declaration I, _____, declare that I am currently licensed as an active direct patient care (name of preceptor).

2 Pharmacist with the NSCP and am currently practicing in a direct patient care setting, interacting directly with patient, and that I have been registered as a pharmacist in Canada for at least one year and further that I have no limitations on Practice and my right to be a preceptor has not been revoked or suspended. I further declare that I have obtained and am covered by professional liability insurance in accordance with the Pharmacy Act and Regulations. I further declare that _____ the pharmacy in which the (name and address of pharmacy). Student/Intern named below intends to serve his/her Practice experience , is currently registered with the nova scotia College of Pharmacists and complies with the Pharmacy Act & Regulations. I further declare that the student named below is registered with the nova scotia College of Pharmacists and will be under my DIRECT personal supervision (or the direct personal supervision of the pharmacist delegate) during his/her training and that I will take responsibility for his/her actions.

3 _____ _____. Signature of Preceptor Date Student/Intern Declaration I, _____, declare that I am currently registered as a Registered Student or Intern . (Student/Intern). with the nova scotia College of Pharmacists and will continue to be registered for the duration of this Practice experience period. I further declare that I have read and understand the Regulations relating to Registered Student/Interns and that I will be under the DIRECT personal supervision of my preceptor named above. _____ _____. Signature of Student Dat