NAME__________________________________________

Yr. & Section ___________

Name of Drugstore _____________________________________ Branch _________________ Address _____________________________________________________________________ Date of Internship _____________________________________________________________ SURVEY TOOL FOR COMMUNITY PHARMACY Dear Students: You are requested to fill up completely this survey tool. There is no right or wrong answer. Your honest evaluation is important to have an accurate conclusion. Thank you for your time. Pharmacy Internship Committee DIRECTIONS: Using the scale below, please encircle the code opposite each item to rate the extent by which each item is practiced or manifested in the drugstore. 4 = Great Extent (GE) 3 = Moderate Extent (ME) 2 = Little Extent 1 = Negligible or Not At All

I. General Provisions: 1. The number of interns accepted is based on the standard ratio of 1:4 (Preceptor to Interns) at any one time. 2. The drugstore provides orientation to the interns prior to the start of the apprenticeship. 3. The drugstore are duly accredited by BFAD and UST. 4. There is a registered pharmacist on duty during the internship training who supervises the intern. 5. There are clear provisions for the basic requirements for operating a drugstore (pharmacist board registration certificate, PRC-ID and display of duly approved LTO in a conspicuous place. 6. There are clear provisions for equipment, chemicals for compounding and dispensing (standard laboratory equipment, prescription balance, pile tile, suppository molder, mortar and pestle, etc. 7. There are clear provisions for reference books and record books duly registered with BFAD (PNDF, USP/NF RPS, Goodman and Gilman Pharmacological Basis of Therapeutics, R.A. 6675, R.A. 5921, R.A. 8203, Prescription Book and Dangerous Drug Book, Exempt Preparation and Poison Book) 8. There is enough space for a pharmacist to observe and supervise all interns assigned in the drugstore. 9. Policies on apprenticeship training schedule and staff-customer relations are reasonable and implemented consistently. 10. The physical-set up of the drugstore is in accordance to the acceptable standard. Pharmacy Internship Program UST Faculty of Pharmacy (AY 2011-2012)

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11. There is clear and open line of communication in the drugstore. 12. The drugstore is properly lighted, well-ventilated and has an area of not less than 15 sq. m. with concrete tile or wooden flooring. 13. The arrangement of furniture allows enough space for movement and work. 14. The drugstore provides a suitable place for adequate storage of drugs and biological products specified on the labels. 15. The drugstores appearance is aesthetically neat and orderly. 16. There are clear provisions for the invoices indicating the lot number/batch number of the manufactures stock pursuant to BFAD, file of prescription filled consecutively numbered, dry seal or rubber stamp, red or white label indicating the number and address of drugstore. 17. There is a summative evaluation of the internship activities and the student performance upon completion of the required number of hours by the intern. 18. The drugstore honors customers privileges i.e. senior citizens card, loyalty card 19. The drugstore provides occasionally additional services to customers i.e. blood pressure monitoring, weight control program and bone density calculations. II. Pharmacist/Personnel Attitudes and Competencies 1. Plans and conceptualize internship activities 2. Meets the needs of the intern 3. Is willing to work long and traditional hours in order to assist interns. 4. Delegates the task fairly 5. Guides the interns in their work of: a. compounding, labeling and packing b. repacking and labeling c. preparing stock solution d. handling of ethical and dangerous drugs e. pricing the prescription f. recording of prescription g. dispensing of drugs h. disseminating drug information i. preparing inventory of drugs and other resources of drugstore. 6. Monitors and evaluates the activities and performance of the interns professionally and fairly 7. Is willing to share his/her management and professional experience/training. 8. Provides or suggests solutions to problems 9. Inspires the interns to work with commitment. 10. Encourages the interns to be respectable and trustworthy. Pharmacy Internship Program UST Faculty of Pharmacy (AY 2011-2012)

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11. Performs consistently the tasks (student related activity) within the Drugstore. 12. Adapts easily to constant change of people, places and things. 13. Treats all interns fairly and honestly. 14. Is courteous and tactful to interns. 15. Relates well to staff and interns III. Facilities 1. Sufficient facilities in good condition are available. 2. Up-to-date facilities are available 3. The physical and material resources are arranged orderly. 4. There is flexibility for the physical and material resources. 5. The physical facilities and compounding areas are clean. 6. The interior design of the drugstore is simple and attractive. IV. Location 1. The site is convenient to customers 2. The drugstore is accessible to public transportation. 3. The drugstore has enough parking space 4. The drugstore has adequate provision for expansion. 5. The drugstore has enough security measures for safety i.e adequate lights, presence of security guard V. Customer/Patient Service 1. The staff has required knowledge and skills i.e. product/drug knowledge to answer customers queries 2. The staff renders prompt and quality service 3. The staff are courteous and approachable. 4. The frontline staff are friendly. 5. The staff communicates clearly with the customers specially on dosing regimen and how the drug should be taken 6. The staff attends to customers comments and feedbacks.

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Pls. rate the drugstore as a whole from 1-5 with 5 as the highest point. _________. Would you personally recommend the drugstore (this branch in particular) as a training site for Pharmacy students in Community Pharmacy? A. Yes B. No Remarks: ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ _____________________________.

Pharmacy Internship Program UST Faculty of Pharmacy (AY 2011-2012)

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