University of Hail ‫ﺟ ﺎﻣ ﻌ ﺔ ﺣ ﺎﺋﻞ‬

College of Pharmacy ‫ﻛ ﻠﯿﺔ اﻟﺼ ﯿﺪ ﻟﺔ‬

Vice deanship for Clinical Training ‫و ﻛ ﺎﻟﺔ اﻟﺘﺪر ﯾﺐ اﻹ ﻛ ﻠﯿﻨﯿﻜ ﻲ‬
Training and internship unit ‫و ﺣ ﺪ ة اﻟﺘﺪر ﯾﺐ و اﻻ ﻣ ﺘﯿ ﺎز‬

Evaluation Template for Clinical Rotations

Preceptor Name: ………………………………….……………. Hospital (organization): ………………………..
Address (distract/governance): ………….…………….…….
Student (Name) under evaluation: ………………….……… Rotation name/ code:………..….………………
Starting date: ………………… Ending date: ………………. Duration/ Total earned hrs: …………………..

Dear Preceptor,
Students are to be formally assessed twice during the rotation, at the midpoint and end of the rotation, using this same
evaluation form. Only Final evaluation counts towards student final grade. Student should achieve an average of >3.0
in each section. The final grade should be >70% (or an average of all 3 domains of > 3.5)
● Midpoint evaluation can be done manually on the hard copy form of this template while the final evaluation
should be filled online electronically.
● Student should be informed with his/her midpoint evaluation (can take a copy) to provide a chance to enhance
his/her performance.
● The following definitions can be used as a guide to assist with the assessment process.
● Each rotation is 5 weeks and by the end of the rotation the student should spend 200 hrs.
● Preceptors are required to provide narrative comments to support very poor and very high scores.

Level of
Score Definition
Competency
Student demonstrates a level of competency superior to his/her peers. Able to
independently and accurately convey knowledge and understanding of the
5 High
topic and display appropriate application of the material (skill) with the
utmost confidence.
Student performs at a level consistent with his/her peers. Accurately conveys
knowledge and understanding and displays application skills with minimal
4 Expected
facilitation by the preceptor. Student displays confidence but may seek
verification from preceptor and/or peers.
Student demonstrates basic competency. Requires preceptor guidance most of
the time in order to accurately convey knowledge and display appropriate
3 Average
application skills. Student requires peer and/or preceptor guidance in order to
be fully confident
Student performs at a level below his/her peers. Needs consistent preceptor
2 Low guidance in order to convey knowledge accurately and appropriately apply it
to practice (skill). Confidence level is below that of an entry-level practitioner
Student performance is poor. Even with preceptor guidance he/she is unable
1 Poor to display understanding and application of knowledge. Lacks the confidence
necessary to progress in the advanced practice experience
Not assessable or No opportunity: demonstration of skills for outcome not
0 NA/NO observed or insufficient to rate students. Or, no opportunities exist on this
rotation to allow student to demonstrate skills.

1/6
updated 10/2017
Tel.: 0165391538
Tel.: 0165391672
 University of Hail ‫ﺟ ﺎﻣ ﻌ ﺔ ﺣ ﺎﺋﻞ‬
College of Pharmacy ‫ﻛ ﻠﯿﺔ اﻟﺼ ﯿﺪ ﻟﺔ‬
Vice deanship for Clinical Training ‫و ﻛ ﺎﻟﺔ اﻟﺘﺪر ﯾﺐ اﻹ ﻛ ﻠﯿﻨﯿﻜ ﻲ‬
Training and internship unit ‫و ﺣ ﺪ ة اﻟﺘﺪر ﯾﺐ و اﻻ ﻣ ﺘﯿ ﺎز‬

Part I: Evaluation of competencies the Intended Learning Outcomes (ILOs) of a clinical rotation (50%)

Question 1 of 10:
Competency (1): Drug/Disease NA/
Poor Low Average Expected High
Items of Assessment (Knowledge) NO
Identifies and thoroughly evaluates current literature and
1. 0 1 2 3 4 5
effectively apply this information to patient care.
Demonstrates knowledge of disease states appropriate for
2. 0 1 2 3 4 5
this clinical setting.
Demonstrates knowledge of evidence based medicine and
3. clinical practice guidelines for disease states common for 0 1 2 3 4 5
this clinical setting.
Describes the expected mechanism of action, therapeutic
response, dosing, adverse effects, and monitoring
4. 0 1 2 3 4 5
parameters for a given drug or combination of drugs/
therapy.
Competency (1) Average Score:

2/6
updated 10/2017
Tel.: 0165391538
Tel.: 0165391672
 University of Hail ‫ﺟ ﺎﻣ ﻌ ﺔ ﺣ ﺎﺋﻞ‬
College of Pharmacy ‫ﻛ ﻠﯿﺔ اﻟﺼ ﯿﺪ ﻟﺔ‬
Vice deanship for Clinical Training ‫و ﻛ ﺎﻟﺔ اﻟﺘﺪر ﯾﺐ اﻹ ﻛ ﻠﯿﻨﯿﻜ ﻲ‬
Training and internship unit ‫و ﺣ ﺪ ة اﻟﺘﺪر ﯾﺐ و اﻻ ﻣ ﺘﯿ ﺎز‬

Question 2 of 10:
Competency (2): Pharmaceutical Care:
NA/
Assessment, Care Plan and follow up evaluation Poor Low Average Expected High
NO
Items of Assessment (Cognitive & Psychomotor)
Use critical thinking and systematic problem-solving
1. 0 1 2 3 4 5
approach to patient care.
Obtains and interprets information from the computer
2. system (records) or patient (verbally) to assess if patient 0 1 2 3 4 5
drug therapy medical chart, needs are met.
Applies physical assessment as appropriate to assist in
3. 0 1 2 3 4 5
evaluating a patient and his/her medication therapy.
Interpret and analyze common clinical laboratory including
knowledge of normal ranges, lab error, and rationale for
4. 0 1 2 3 4 5
ordering specific tests and optimal utilization and
application of results.
Consistently and accurately identifies and prioritizes all
5. 0 1 2 3 4 5
medication-related problems.
Establish desired therapeutic outcomes (goals of therapy)
6. 0 1 2 3 4 5
that are patient specific.
Design appropriate therapeutic care plan incorporating
7. patient factors and comorbidities, drug product and 0 1 2 3 4 5
pharmacokenitic and site formulary.
8. Incorporate non-drug therapy alternatives appropriately. 0 1 2 3 4 5
Design and implement a timely and ongoing monitoring
9. 0 1 2 3 4 5
plan to assess the outcomes of drug therapy for a patient.
Adjusts regimens based on patient physiologic parameters
10. 0 1 2 3 4 5
and response to therapy.
Document pharmaceutical care activity in the patient's
11. medical record to facilitate communication and 0 1 2 3 4 5
collaboration among providers.
Identify, assess and appropriately report drug related
12. 0 1 2 3 4 5
problems, adverse events, drug interactions and toxicities.
Assesses patient adherence to medications and identify risk
13. 0 1 2 3 4 5
factors for non-adherence.
Competency (2) Average Score:

3/6
updated 10/2017
Tel.: 0165391538
Tel.: 0165391672
 University of Hail ‫ﺟ ﺎﻣ ﻌ ﺔ ﺣ ﺎﺋﻞ‬
College of Pharmacy ‫ﻛ ﻠﯿﺔ اﻟﺼ ﯿﺪ ﻟﺔ‬
Vice deanship for Clinical Training ‫و ﻛ ﺎﻟﺔ اﻟﺘﺪر ﯾﺐ اﻹ ﻛ ﻠﯿﻨﯿﻜ ﻲ‬
Training and internship unit ‫و ﺣ ﺪ ة اﻟﺘﺪر ﯾﺐ و اﻻ ﻣ ﺘﯿ ﺎز‬

Question 3 of 10:
Competency (3): Communication, Responsibilities &
NA/
Interpersonal Skills Poor Low Average Expected High
NO
Items of Assessment
1. Demonstrates active listening skills and empathy. 0 1 2 3 4 5
Effectively communicates both verbally and in writing with
2. 0 1 2 3 4 5
preceptor, patients and other health care professionals.
Demonstrates the ability to establish effective relationships
3. 0 1 2 3 4 5
with other health care professionals and patients.
Demonstrates appropriate willingness to form an opinion,
4. 0 1 2 3 4 5
express observations and/or ask questions.
5. Displays effective presentation skills. 0 1 2 3 4 5
Demonstrates assertiveness and confidence when making
6. 0 1 2 3 4 5
recommendations.
Responds to questions in a clear and concise manner with
7. 0 1 2 3 4 5
supporting evidence/rationale.
Demonstrates the ability to synthesize and integrate
information(clinical, cultural, ethical, economic and legal)
8. 0 1 2 3 4 5
effectively when making practice- and/or patient care
related decisions.
Demonstrates an appreciation of the roles and
9. 0 1 2 3 4 5
responsibilities of other healthcare providers.
Competency (3) Average Score:

N.B.:
Student Final Grade ((total score of 3 domains/130)* x 100)
*: NA/NO competencies should be excluded from the total score and from 130 as 5 per competency

4/6
updated 10/2017
Tel.: 0165391538
Tel.: 0165391672
 University of Hail ‫ﺟ ﺎﻣ ﻌ ﺔ ﺣ ﺎﺋﻞ‬
College of Pharmacy ‫ﻛ ﻠﯿﺔ اﻟﺼ ﯿﺪ ﻟﺔ‬
Vice deanship for Clinical Training ‫و ﻛ ﺎﻟﺔ اﻟﺘﺪر ﯾﺐ اﻹ ﻛ ﻠﯿﻨﯿﻜ ﻲ‬
Training and internship unit ‫و ﺣ ﺪ ة اﻟﺘﺪر ﯾﺐ و اﻻ ﻣ ﺘﯿ ﺎز‬

Part II: Student Activities (20-30%)

- The following are activities that need to be completed by students. although not showing on the final grade,
incompletion of such activities will jeopardize student passing the rotation.
Question 4 of 10:
Please verify students’ completion of the required activities.
S.N. Activities NA/NO Poor Low Average Expected High
1. Case/drug presentation 0 1 2 3 4 5
2. Medication history 0 1 2 3 4 5
3. SOAP notes 0 1 2 3 4 5
4. Health awareness activity 0 1 2 3 4 5
5. Journal club 0 1 2 3 4 5
6. Drug monograph 0 1 2 3 4 5
7. Educational Brochures 0 1 2 3 4 5
8. A comparison of the most common therapy 0 1 2 3 4 5
Others
9. 0 1 2 3 4 5
Specify:

Grade should reflect degree of satisfaction regarding student activity in the mean of performance & time
Part III: Student Commitment (20-30%)
- Student non-compliance will jeopardize passing the rotation as uncommitted student may get F (Fail) or IC
(Incomplete) grade or his/her final grade will be affected.
Question 5 of 10:
How many sick days did the student take during this rotation?
None 1 2 3 4 more specify ………..
Student need to compensate these days to not affect the ILOs of the rotation.
No need to compensate these days & the ILOs of the absence days were repeated.
Student compensates these days in coordination with the preceptor.

Question 6 of 10:
How many excused days did the student take during this rotation?
None 1 2 3 4 more specify ………..
Student need to compensate these days to not affect the ILOs of the rotation.
No need to compensate these days & the ILOs of the absence days were repeated.

5/6
updated 10/2017
Tel.: 0165391538
Tel.: 0165391672
 University of Hail ‫ﺟ ﺎﻣ ﻌ ﺔ ﺣ ﺎﺋﻞ‬
College of Pharmacy ‫ﻛ ﻠﯿﺔ اﻟﺼ ﯿﺪ ﻟﺔ‬
Vice deanship for Clinical Training ‫و ﻛ ﺎﻟﺔ اﻟﺘﺪر ﯾﺐ اﻹ ﻛ ﻠﯿﻨﯿﻜ ﻲ‬
Training and internship unit ‫و ﺣ ﺪ ة اﻟﺘﺪر ﯾﺐ و اﻻ ﻣ ﺘﯿ ﺎز‬

Student compensates these days in coordination with the preceptor.

Question 7 of 10: (Confidential)
Were there any issues about the student's professionalism that the college needs to know about? (This question is
confidential and will not be seen by the student).
…………………………………………………………………………………………………………………………
…………………………………………………………………………………………………………………………
Part IV: Overall Assessment

Question 8 of 10:
Learning Achievements (Strengths/Accomplishments):
…………………………………………………………………………………………………………………………
…………………………………………………………………………………………………………………………
…………………………………………………………………………………………………………………………
…………………………………………………………………………………………………………………………
Question 9 of 10:
Learning Needs (Needs improvement):
…………………………………………………………………………………………………………………………
…………………………………………………………………………………………………………………………
…………………………………………………………………………………………………………………………
…………………………………………………………………………………………………………………………

Question 10 of 10:
After reviewing the student's overall performance, the student's rotation status is:
Pass (NP) Fail (F) Incomplete (IC)

Preceptor Signature/ Date

……………………………
……………………………

6/6
updated 10/2017
Tel.: 0165391538
Tel.: 0165391672