Pharmacist Form 4b - Certification Of Completion Of Pharmacy Practice Residency Competencies - New York The State Education Department Page 2
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1
2
3Section II: Pharmacy Residency Program Certification
INSTRUCTIONS: As a pharmacist residency program director you must:
1.
Complete this Section, read, sign and date the certification below, and have your signature notarized by a Notary Public.
2.
Send all pages of the completed form, measurement standards (see sample provided) as well as detailed information on
measurement standards utilized for assessment of competencies to the address at the end of this page.
Name of resident: _________________________________________________________________________________________________
(See Section I, item 3)
Name of residency program: _________________________________________________________________________________________
Date entered residency program: _______ / _______ / _______
mo.
day
yr.
Date completed the required competencies: _______ / _______ / _______
mo.
day
yr.
I am the residency program director and I hereby certify that:
1.
The statements made on this form regarding this applicant's pharmacy practice residency experience are true, complete and
correct; and
2.
the applicant has successfully achieved each of the following competencies as part of a residency program in pharmacy practice
approved by the Department (check all that apply):
sterile product preparation and technique;
non-sterile compounding preparation and technique;
performing dosing calculations, including but not limited to aliquot, proportions, and infusion drip-rates;
medication safety procedures, including, but not limited to, identifying potential look-alike and sound-alike drugs and other
medication error prevention techniques;
drug distribution, including but not limited to preparing, dispensing and verifying the accuracy of filled prescriptions or
medication orders; and
such other competencies in pharmacy practice as may be required by the department; and
3.
the assessment of these competencies was made in an objective fashion, the methods of which will be shared with the
Department.
The undersigned affirms under penalty of perjury that the answers and statements that he/she has made in the above application are true
and have been made and given with the intent of having the New York State Education Department and the New York State Board of
Pharmacy rely on the truth thereof.
Signature of Residency Program Director: _________________________________________________ Date: _______ / _______ / _______
mo.
day
yr.
Print name: ______________________________________________________________________________________________________
License number: __________________________________ State in which you are licensed: ______________________________________
Institution name: __________________________________________________________________________________________________
Address: _________________________________________________________________________________________________________
City: ______________________________________________________ State: _____________________ Zip code ___________________
Telephone: _________________________ Fax: _________________________ Email: __________________________________________
Notary
State of __________________________________________________ County of __________________________________________ On
the ________________ day of __________________________ in the year __________ before me, the undersigned, personally appeared
__________________________, personally known to me or proved to me on the basis of satisfactory evidence to be the individual whose
name is subscribed to this application and acknowledged to me that he/she executed the certification.
Notary Public signature _________________________________________________________________________________________
Notary ID number _______________________________
Notary Stamp
Expiration date __________ / __________ / __________
Month
Day
Year
Return Directly to: New York State Education Department, Office of the Professions, Division of Professional Licensing Services,
Pharmacy Unit, 89 Washington Avenue, Albany, NY 12234-1000.
Pharmacist Form 4B, Page 2 of 2, Rev. 2/14
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