Master Forms - National Pharmacy Association€¦ · NPA Level 3 Diploma (NVQ) (QCF) in Pharmacy...
32
Knowledge Based Qualification for the NVQ3 (QCF) Diploma in Pharmacy Service Skills Master Forms
Transcript of Master Forms - National Pharmacy Association€¦ · NPA Level 3 Diploma (NVQ) (QCF) in Pharmacy...
Knowledge Based Qualification for the NVQ3 (QCF) Diploma in Pharmacy Service Skills
Master Forms
Copyright © NPA 2016. All rights reserved. No part of
this publication may be reproduced, stored in a retrieval
system or transmitted in any form, or by any means
technical, photocopying, recording or otherwise, without
prior permission from the NPA.
© NPA 2016 1© 2013 National Pharmacy Association 1
NPA Level 3 Diploma (NVQ) (QCF) in Pharmacy Service Skills
Master Forms This pack contains a template copy of all the forms you will need when building your portfolio. You can also access electronic copies of the forms on the member’s section of the NPA website, under resources.
Portfolio Submission Form
Malpractice and Plagiarism Declaration
Personal Profile Form
Summary of Student’s Achievements
Activity Log
Expert Witness Observation – Planning Record (For Expert Witness)
Witness Information List
Copy of Prescription – (For Simulations and Supporting Documentation)
Evidence Index Forms
Unit Assessment and Verification declaration
2
3
4
5
7
8
9
10 11–27
28
Note: Please note the format of the template forms must not be altered; this is especially important when using the Activity Report forms as the witness and candidate signature and date must be present on all pages.
NVQ3 (QCF) Diploma in Pharmacy Service Skills
2 © NPA 2016© 2013 National Pharmacy Association 2
PORTFOLIO SUBMISSION FORM You must complete this form and submit it each time you send your work for assessment. Please put this form at the top.
STUDENT NAME…………………………………………………………...
STUDENT NUMBER……………………………………………………….
Please indicate which Unit/s you are submitting
UNIT/S NUMBER SUBMITTED…………………………………………
RESUB UNIT/S NUMBER SUBMITTED…………………………………
PORTFOLIO CHECK LIST
Please ensure that you have included the following paperwork
PERSONAL PROFILE FORM
SUMMARY OF STUDENT’S ACHIEVEMENTS
UNIT VERIFICATION FORM
EVIDENCE INDEX SHEETS
ACTIVITY REPORTS WITH EVIDENCE
WITNESS INFORMATION LIST
A COPY OF YOUR EXPERT WITNESS’ CERTIFICATE MALPRACTICE AND PLAGIARISM DECLARATION
© NPA 2016 3© 2013 National Pharmacy Association 3
Malpractice and Plagiarism Declaration NPA NVQ3 (QCF) Diploma in Pharmacy Services Skills
Unit Number: Unit Title:
Candidate Declaration I confirm I have read and understood the NPA Malpractice and Plagiarism Policy. I confirm that the attached portfolio does not breach this policy and that:
• All attached work is a true reflection of the activities undertaken by myself • All supporting documentation is authentic and relevant to the activities I have
undertaken; no supporting documentation has been forged or altered in any way • All work is my own and has been completed individually • No aspects of the attached portfolio have been copied from another student or
source and no collusion has taken place.
Candidate Name: NPA Student Number:
Candidate Signature: Date:
Supervising Pharmacist Declaration
I confirm I have read and understood the NPA Malpractice and Plagiarism Policy. I have reviewed my candidate’s attached portfolio and can confirm that it does not breach this policy and that:
• I have witnessed the activity reports signed by myself and the accounts are a true reflection of the activity undertaken by my candidate
• I have reviewed the candidate’s supporting documentation and can confirm it is authentic and relevant to the activities the candidate has undertaken; no supporting documentation has been forged or altered in any way
• All work is the candidate’s own and has been completed individually • No aspects of the attached portfolio have been copied from another student or
source and no collusion has taken place.
Supervising Pharmacist Name: GPhC Number:
Supervising Pharmacist Signature: Date:
4 © NPA 2016© 2013 National Pharmacy Association 4
PERSONAL PROFILE FORM
Name of Candidate: Student No: Candidate Address: Email address:
Pharmacy Address: (including postcode) Pharmacy Telephone Number:
NPA / Account Number:
Summary of Qualifications:
Courses Attended (dates):
Brief Employment History:
Personal Interests:
Current Job Description – with Key Responsibilities and Key Tasks:
© NPA 2016 5© 2013 National Pharmacy Association 5
Summary of Student’s Achievements PHARMACY SERVICES LEVEL 3
Student Name: Student Number: Start Date:
Unit
Title
Date Achieved
Candidate Signature
Assessor Signature IV Signature
SV SignatureUnit Obs. P.D
1
Ensure Your own actions reduce risks to Health and Safety
2
Provide an effective and responsive pharmacy service
3
Process pharmaceutical Queries
4
Reflect on and develop your practice
5
Receive prescriptions from individuals
6
Confirm prescription validity
7
Assemble prescribed items
8
Issue prescribed items
9
Prepare extemporaneous medicine for individual use
6 © NPA 2016© 2013 National Pharmacy Association 6
Summary of Student’s Achievements PHARMACY SERVICES LEVEL 3
Student Name: Student Number: Start Date:
Unit
Title Date
achieved Candidate signature
Assessor signature IV signature
SV signatureUnit Obs. P.D
10
Order Pharmaceutical stock
11
Receive Pharmaceutical stock
12
Maintain pharmaceutical stock
13
Issue pharmaceutical stock
14
Undertake an in- process accuracy check of assembled prescribed items prior to final accuracy check
16 Assist in the sale of Medicines and products
Initial to confirm MCA certificate seen:
18 Provide advice on symptoms and the actions and uses of medicines
Initial to confirm MCA certificate seen:
25
Process prescriptions for payment
© NPA 2016 77
w itness Testimony
Evidence Ref
Activity Log
Page
of
Type of Evidence Professional Discussion
Prof essional Discussion
Witness Testimony
Exp Witness Observation
Pharmacy stamp
Simulation
Unit AC
Description of Activity:
Oral/Written Questions
Date of Activity:
Supporting documentation attached: e.g. photographs copies of prescriptions etc: I confirm that I witnessed the candidate undertaking the activity described above. I confirm that the candidate has covered the units and assessment criteria mentioned above. Additional Comments:
Name of Candidate:
Sign: Date:
Name of Witness/ Expert Witness/Assessor:
Sign: Date:
GPHC Reg. No:
8 © NPA 2016
Unit AC
I confirm that I witnessed the candidate undertaking the activity described above. I confirm that the candidate has covered the units and assessment criteria mentioned above. Additional Comments: Name of Candidate: _________________________________________________________ Sign:_____________________________________________ Date: ___________________ Name of Witness/ Expert Witness/Assessor:_____________________________________________________ Sign:_____________________________________________ Date: ___________________ GPhC Reg. No: _________________________
Activity Log – Continuation Sheet
WITNESS INFORMATION LIST
l the undersigned have read the supervisor's guide and understand the process. l have witnessed the candidate in action and have signed the witness testimonies to verify this.
Name Job Title & Work Telephone No. Signature lnvolvement with
Candidate Expert
Witness Y/N
© 2013 National Pharmacy Association g
© NPA 2016 9
WITNESS INFORMATION LIST
l the undersigned have read the supervisor's guide and understand the process. l have witnessed the candidate in action and have signed the witness testimonies to verify this.
Name Job Title & Work Telephone No. Signature lnvolvement with
Candidate Expert
Witness Y/N
© 2013 National Pharmacy Association g
10 © NPA 2016
COPY OF PRESCRIPTION
I declare that this is a true copy of the prescription and this prescription has not been used by any other students:
Candidate Signature:
Pharmacist/Expert Witness Name: Date:
Pharmacist/Expert Witness signature: Date:
GPhC No.:
© 2013 National Pharmacy Association 10
© NPA 2016 11
COPY OF PRESCRIPTION
I declare that this is a true copy of the prescription and this prescription has not been used by any other students:
Candidate Signature:
Pharmacist/Expert Witness Name: Date:
Pharmacist/Expert Witness signature: Date:
GPhC No.:
© 2013 National Pharmacy Association 10
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ture
:
Dat
e:
IV
Sig
natu
re a
nd D
ate:
©
201
3 N
atio
nal P
harm
acy
Asso
ciat
ion
© NPA 2016 21
Uni
t 11
Evid
ence
Inde
x: R
ecei
veph
arm
aceu
tical
stoc
k
© 2
013
Nat
iona
l Pha
rmac
y As
soci
atio
n
21
Evid
ence
R
ef &
D
escr
iptio
n
Evid
ence
Ty
pe *
Lear
ning
Out
com
e 1
Lear
ning
Out
com
e 2
Lear
ning
O
utco
me
3 Le
arni
ng O
utco
me
4 Le
arni
ng O
utco
me
5 Le
arni
ng
Out
com
e 6
1.1
1.2
1.3
1.4
1.5
2.1
2.2
2.3
2.4
3.1
3.2
3.3
4.1
4.2
4.3
4.4
4.5
4.6
5.1
5.2
5.3
5.4
6.1
6.2
2
1 2
2 2
2
2 2
1
1
2 2
1
1 1
1 2
1
1
1 2
2
2
2
Num
ber o
f as
sess
men
t cr
iteria
cl
aim
ed
Your
qua
ntity
Min
imum
no.
* Evi
denc
e Ty
pe W
T=W
itnes
s Te
stim
ony
O=O
bser
vatio
n PD
=Pro
fess
iona
l Dis
cuss
ion
Q=Q
uest
ioni
ng S
=Sim
ulat
ion
C
andi
date
Sig
natu
re:
D
ate:
Inte
rnal
Ver
ifier
Nam
e:
Asse
ssor
Sig
natu
re:
D
ate:
IV S
igna
ture
and
Dat
e:
22 © NPA 2016
© 2
013
Nat
iona
l Pha
rmac
y As
soci
atio
n
Uni
t 12
Evid
ence
Inde
x: M
aint
ain
phar
mac
eutic
alst
ock
22
Evid
ence
Ref
&
Des
crip
tion
Evid
ence
Ty
pe *
Lear
ning
O
utco
me
1 Le
arni
ng O
utco
me
2 Le
arni
ng O
utco
me
3 Le
arni
ng O
utco
me
4 Le
arni
ng
Out
com
e 5
1.1
1.2
2.1
2.2
2.3
2.4
2.5
3.1
3.2
3.3
3.4
3.5
4.1
4.2
4.3
5.1
5.2
5.3
2
1
2
2 2
2 1
2
1 1
1 1
1
2 1
2
2 1
Num
ber o
f as
sess
men
t cr
iteria
cla
imed
Your
quan
tity
M
inim
umno
.
* Evi
denc
e Ty
pe W
T=W
itnes
s Te
stim
ony
O=O
bser
vatio
n PD
=Pro
fess
iona
l Dis
cuss
ion
Q=Q
uest
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ng S
=Sim
ulat
ion
C
andi
date
Sig
natu
re:
D
ate:
Inte
rnal
Ver
ifier
Nam
e:
Asse
ssor
Sig
natu
re:
D
ate:
IV S
igna
ture
and
Dat
e:
© NPA 2016 23
Uni
t 13
Evid
ence
Inde
x: Is
sue
phar
mac
eutic
alst
ock
Asse
ssor
Sig
natu
re:
D
ate:
© 2
013
Nat
iona
l Pha
rmac
y As
soci
atio
n
IVSi
gnat
ure
and
Dat
e:
23
Evid
ence
R
ef &
D
escr
iptio
n
Evid
ence
Type
* Le
arni
ng O
utco
me
1 Le
arni
ng
Out
com
e 2
Lear
ning
Out
com
e 3
Lear
ning
Out
com
e 4
Lear
ning
O
utco
me
5 1.
1 1.
2 1.
3 1.
4 1.
5
a b
c d
e
2.1
2.2
2.3
3.1
3.2
3.3
3.4
3.5
4.1
4.2
4.3
4.4
4.5
4.6
5.1
5.2
1
2 2
2 2
2 2
1 1
2
2 2
2
2 2
2 1
2
1 1
1 1
1
2
2
Num
ber o
f as
sess
men
t cr
iteria
cl
aim
ed
Your
qua
ntity
Min
imum
no.
* Evi
denc
e Ty
pe W
T=W
itnes
s Te
stim
ony
O=O
bser
vatio
n PD
=Pro
fess
iona
l Dis
cuss
ion
Q=Q
uest
ioni
ng S
=Sim
ulat
ion
C
andi
date
Sig
natu
re:
D
ate:
Inte
rnal
Ver
ifier
Nam
e:
24 © NPA 2016
Asse
ssor
Sig
natu
re:
D
ate:
© 2
013
Nat
iona
l Pha
rmac
y As
soci
atio
n
IVSi
gnat
ure
and
Dat
e:
24
Uni
t 14
Evid
ence
Inde
x: U
nder
take
an
in-p
roce
ss a
ccur
acy
chec
k of
ass
embl
ed p
resc
ribed
item
s pr
ior t
o th
e fin
al
accu
racy
che
ck
Evid
ence
R
ef &
D
escr
iptio
n
Evid
ence
Ty
pe *
Lear
ning
O
utco
me
1
Lear
ning
Out
com
e 2
Lear
ning
Out
com
e 3
L.O
4 Le
arni
ng O
utco
me
5 Le
arni
ng
Out
com
e 6
1.1
1.2
2.1
2.2
2.3
2.4
2.5
2.6
2.7
3.1
3.2
3.3
3.4
4.1
5.1
5.2
5.3
5.4
5.5
5.6
5.7
6.1
6.2
1
1
2
2 2
2 2
2 2
2
2 2
1
2
2
2 2
2 2
1 1
2
2
Num
ber o
f as
sess
men
t cr
iteria
cl
aim
ed
Your
qua
ntity
min
imum
no.
* Evi
denc
e Ty
pe W
T=W
itnes
s Te
stim
ony
O=O
bser
vatio
n PD
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fess
iona
l Dis
cuss
ion
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uest
ioni
ng S
=Sim
ulat
ion
C
andi
date
Sig
natu
re:
D
ate:
Inte
rnal
Ver
ifier
Nam
e:
© NPA 2016 25
Uni
t 16
Evid
ence
Inde
x: A
ssis
t in
the
sale
ofm
edic
ines
and
prod
ucts
© 2
013
Nat
iona
l Pha
rmac
y As
soci
atio
n
25
Evid
ence
Ref
&
Des
crip
tion
Evid
ence
Ty
pe *
Lear
ning
O
utco
me
1 Le
arni
ng O
utco
me
2 Le
arni
ng
Out
com
e 3
Lear
ning
Out
com
e 4
Lear
ning
Out
com
e 5
1.1
1.2
2.1
2.2
2.3
2.4
3.1
3.2
4.1
4.2
4.3
4.4
5.1
5.2
5.3
Num
ber o
f as
sess
men
t cr
iteria
cla
imed
Your
qua
ntity
Min
imum
no.
2
2
2
2 2
2
2
2
2
2 2
2
1
1 1
* Evi
denc
e Ty
pe W
T=W
itnes
s Te
stim
ony
O=O
bser
vatio
n PD
=Pro
fess
iona
l Dis
cuss
ion
Q=Q
uest
ioni
ng S
=Sim
ulat
ion
C
andi
date
Sig
natu
re:
D
ate:
Inte
rnal
Ver
ifier
Nam
e:
Asse
ssor
Sig
natu
re:
D
ate:
IV S
igna
ture
and
Dat
e:
26 © NPA 2016
© 2
013
Nat
iona
l Pha
rmac
y As
soci
atio
n
Uni
t 18
Evid
ence
Inde
x: P
rovi
dead
vice
onsy
mpt
oms
and
the
actio
ns a
ndus
esof
med
icin
es 26
Evid
ence
Ref
&
Des
crip
tion
Evid
ence
Ty
pe *
Lear
ning
Out
com
e 1
Lear
ning
Out
com
e 2
2.
1 2.
2 2.
3 2.
4 2.
5
Lear
ning
Out
com
e 3
3.
1 3.
2 3.
3 3.
4 3.
5
Lear
ning
O
utco
me
4 1.
1 1.
2 1.
3 1.
4 1.
5 1.
64.
1 4.
2
2
2 2
2 2
2
2
2 2
2 2
1
2 2
2 2
2
2
Num
ber o
f as
sess
men
t cr
iteria
cl
aim
ed
Your
quan
tity
M
inim
umno
.* E
vide
nce
Type
WT=
Witn
ess
Test
imon
y O
=Obs
erva
tion
PD=P
rofe
ssio
nal D
iscu
ssio
n Q
=Que
stio
ning
S=S
imul
atio
n
Can
dida
te S
igna
ture
:
Dat
e:
In
tern
al V
erifi
er N
ame:
As
sess
or S
igna
ture
:
Dat
e:
IV
Sig
natu
re a
nd D
ate:
© NPA 2016 27
© 2
013
Nat
iona
l Pha
rmac
y As
soci
atio
n
Uni
t 25
Evid
ence
Inde
x: P
roce
sspr
escr
iptio
nsfo
rpay
men
t
27
Evid
ence
Ref
&
Des
crip
tion
Evid
ence
Ty
pe *
Lear
ning
Out
com
e 1
Lear
ning
Out
com
e 2
Lear
ning
O
utco
me
3 1.
1 1.
2 1.
3 1.
4 1.
5 1.
6 2.
1 2.
2 2.
3 3.
1 3.
2 N
umbe
r of
asse
ssm
ent c
riter
ia
clai
med
Your
qua
ntity
Min
imum
no.
2
2 2
2 2
2
2
2 2
1
1 * E
vide
nce
Type
WT=
Witn
ess
Test
imon
y O
=Obs
erva
tion
PD=P
rofe
ssio
nal D
iscu
ssio
n Q
=Que
stio
ning
S=S
imul
atio
n
Can
dida
te S
igna
ture
:
Dat
e:
In
tern
al V
erifi
er N
ame:
As
sess
or S
igna
ture
:
Dat
e:
IV
Sig
natu
re a
nd D
ate:
28 © NPA 2016
UNIT ASSESSMENT AND VERIFICATION DECLARATION
N/SVQ Title:
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© 2013 National Pharmacy Association 28
NPA NVQ3 (QCF) Diploma in Pharmacy Services Skills
Student Name: _________________________ Student Number: _________________ Expert Witness Name: ___________________ Planned Date for Observation: __________________________ Planned Activity for Observation and Preparation Required: ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ Units and Learning Outcomes/Assessment Criteria Identified to Cover During Activity: ___________________________________________________________________________________________________________________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________________________________________________________________________________________________________________
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