Affidavit Form
First Name
Diploma
Last Name
Declaration of Completion of the Affidavit I, ________________________________________a registrant on the Register of Pharmacists of the
(print name)
College of Pharmacists of British Columbia, declare that in my professional activities, I do not perform or supervise/manage others in direct patient care activities, and will not do so after I have signed this Affidavit. I have confirmed this by filling in the bubbles to the corresponding functions and activities in Role 1, Role 2, and Role 3E of the Framework of Professional Practice on Page 2 of this document. This means that I do not/will not: work in a pharmacy as a pharmacist on an occasional basis "fill in" as a pharmacist on an occasional basis directly counsel, dialogue with and/or provide information to patients and/or practitioner about specific patients' drug therapy including prescription and nonprescription medications, be the designated pharmacy manager of a licensed pharmacy and/o supervise/manage others in any of the above activities I understand that before I perform or supervise/manage others in direct patient care activities I must first: successfully meet the standards of the Professional Development and Assessment Progra prior to transferring to active status on the Register of Pharmacists, and complete other requirements, as require I understand that I must provide a written request to the College of Pharmacists of B.C. of any change in my status.
By signing the Affidavit, you remain on the Register of Pharmacists (practising register) but are restricted from performing, supervising or managing direct patient care activities. Please be sure to read and understand the restrictions on your practice and the requirements for returning to active practice in the Return-to-Practice Information Guide before you sign the Affidavit. The procedures to return to active practice will differ depending on the length of time you have signed the Affidavit.
Signature :
Date :
Upon completion, fax this 2 page Affidavit form to the PDAP office fax line [604] 676-4228. All forms are to be completed and received at the office by Please also mail your original completed form and signed Affidavit to the College Office. Be sure to make a photocopy for your files. 0560041185
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Affidavit Form
Role 1 Provide pharmaceutical care
I confirm that I do not perform or supervise/manage others in any of the functions and activities in Role 1 of the Framework of Professional Practice as noted below:
Function A: Assess the client's health status and needs
Activity 1 Activity 2 Activity 3 Activity 1 Activity 2 Activity 3 Activity 4 Activity 1 Activity 2 Activity 3 Activity 1 Activity 2 Activity 1 Activity 2 Establish and maintain a relationship with the client Obtain information about the client's health Determine the client's desired health outcomes and priorities Formulate care plan options Make recommendations to meet the client's need Support the client to select (a) care plan option(s) Refer the client to other services Enable the client to maximize health outcomes Provide drug therapy and devices Provide information Obtain and evaluate information on the client's progress with the care plan Confirm or modify the client ’s care plan Document information Maintain and store information
Function B: Develop a care plan with the client
Function C: Support the client to implement the care plan
Function D: Support and monitor the client's progress with the care plan
Function E: Document findings, follow-ups, recommendations, information provided and client outcomes
Role 2
Produce and distribute drug preparation and products
I confirm that I do not supervise/manage others but may perform under supervision any of the functions and activities in Role 2 of the Framework of Professional Practice as noted below:
Function A: Produce drug preparations and products
Activity 1 Activity 2 Activity 3 Activity 1 Activity 2 Prepare pharmaceutical products Package pharmaceutical products Create and maintain records Maintain storage environment Maintain storage system
Function B: Store drug preparations and products
Function C: Distribute drug preparations and products Activity 1 Maintain security and integrity during the distribution process
Activity 2 Activity 1 Activity 2 Activity 3 Maintain records of distribution Identify products requiring disposal Store products requiring disposal securely Remove products from pharmacy for disposal
Function D: Dispose of drug preparations and products
Role 3 Contribute to the effective operation of the pharmacy
I confirm that I do not perform or supervise/manage others in any of the functions and activities in Role 3E of the Framework of Professional Practice as noted below:
Function E: Minimize practice errors and omissions, unsafe practices and professional misconduct
Activity 1 Activity 2 Activity 3 Identify and prevent practice errors/omissions, unsafe practices and professional misconduct Minimize, manage and report practice errors and omissions Respond to and resolve unsafe practices and professional misconduct
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