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(To Be Completed By Peer-Evaluator)

Name of Student being evaluated:______________________________________________

Name of Evaluator:______________________________________________

At a minimum, did the student cover each of the following points during counseling?

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1. Introduced self and verified correct patient Y N Somewhat
2. Brand and generic name Y N Somewhat
3. Indication Y N Somewhat
4. Directions for taking Y N Somewhat
5. Common AND serious SE Y N Somewhat

Assessment of student performance:

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6. Did student communicate all necessary information? (special instructions or precautions) Y N Somewhat
7. Did the student maintain good eye contact? Y N Somewhat
8. Did the counseling flow smoothly and end well? Y N Somewhat
9. Did the patient receive the message communicated? Y N Somewhat

Observations from group members

Did the student handle the situation appropriately? Explain specifically what was done well.

How could the student have handled the situation differently? Explain what could have been done to improve the counseling, the situation, or the outcome.

*Rubric was created by Brittney Meyer, Pharm.D.

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