APPRAISAL BY PRINCIPAL PRECEPTOR

Name of Provisionally Registered pharmacist

[pRp]:

..T9.$.t ?Jr 5Rl6trNAN/

l/C Number: .,. .q?9,L91t.- 99

-6ca+

PRP Registration Number:

6{08

Place of Train

in g

: .. .U?!f. !L?,1. . .f5.

l9t(

IMI+IN

I certify that the above PRP has completed his/ her training as required under

subsection 64 (2) of the Registration of pharmacists Act 1951

1. Proposal:

1A. The above PRP has obtained average mark

18.

/tC

H'e/ She has

of:

1g

.3( % and

"passed/ fui+ed the Pharmacy Jurisprudence Examination

C:!:!:?!? of

satisfactory experience in accordance to sub-regutation T(1)

Registration of Pharmacisfs Regutations 2004 is recommendel
b be given
to him/ her.

of satisfactory experience in accordance to sub-regutation

I tD C:!:!:?:?
Registration of Pharmacisfs Regulations 2004
given to *him/ her and

t E.

"He/ she needs to extend the training for another

in UniUSection

*He/ She needs to

7(1)

is not recomiended to be
month/s;

*or/and

Examination

pass

the

Pharmacy Jurisprudence

2. Principal Preceptor's detail:

2.1 Name:
2.2 Office address:
2.3 Principal Preceptor's
2.4 Date: u lt 6ll*

ZAWIAH BT ZAINAL
Pegawai Farmasi Gred Usl
Jabahn Farmasi
Hwpital Teluk lnbn

signature:

Pharmacy Board Mataysia 2011

Setiausaha
Lembaga Farmasi Malaysia
Bahagian Perkhidmatan Farmasi
Kementerian Kesihatan Malaysia
Beg Berkunci No.924
Pejabat Pos Jalan Sultan
46790 PETALING JAYA

PROPOSAL OF FULL REGISTRATION

Name of Provisionally Registered pharmacist
[pRp]:
t/c Number: .......9LT.9.1...99.:..93i1
PRP Registration

Number:

F}E/N A

Af
P KR,S+NANJ
..r.'...

..{1gB

Place of Training: . .. . .. . .. ..Ws.Plln

|1

..

Lf

lyf

r{TNN

I certify that the above PRp has completed his/ her training
subsection 64 (2) of the Registration of Pharmacists
Act
1951

as required

under

1. Proposal:

1A' certificate of satisfactory experience in accordance

to sub-regulation 7(1)
Registration of Pharmacisis Regutations zooq*recommended/
is
na(
rgQffiiTtffided to be given to him/ her and
*quarifie,it
she is
Fe/
io,drn
a
for Full Reqistration.

18. .He/ sl:_1qeds to extend the training

for another
from (date):.
to

month/s
(date).

1C. The extension of the trainingis because;

I
I

i)

His

/her performance was below 60% or /and

iD He/ she needs fo pass the pharmacy

Jurisprudence Examination

2. Master Preceptor's detail:

2.1 Name:
2.2 Office address:
2.3 Master Preceptor's signature: ... ...
2.4 Date:

UNOS BIN SI{A f\RI

gerah Kesihatan Negeri

Jabaian Kesihatan

y Board Malaysia 2011

Setiausaha
Lembaga Farmasi Malaysia
Bahagian Perkhidmatan Farmasi
Kementerian Kesihatan Malaysia
Beg Berkunci No.g24
Pejabat Pos Jalan Sultan
46790 PETALING JAYA

APPRAISAL OF PRECEPTORS
Name of Provisionally Registered pharmacist
[pRp]: . ..?.=rn.p... t1 P

l/c

{ftqfNA^,

Number: ... ...ry919.i{. .9.{.. .93.:1.

-

PRP Registration

Number:

.-g:gl.
TaL\JIL

,O

TAN

I have undergone training at the above ptace from (date

): 4 ln ltz to: 4ltt I t+ (date)

C. Professional

Guidance by
Preceptors

Comment (how things can be inpraved); p/ease make attachment where necessaryj

D. Training

Skills of The
Preceptors

comment(how fhings can be improved); please make aftachment where necessary)

Pharmacy Board Malaysia 2011

"i tt

6.1 Demonstrate a Professionat

Approach

Assessment

HospitalTertiary

1. Action and
z.

attitudes are demonstrated which indicate

commitment to quality of pharmaceutical care of the patient
A pollte and helpful manner is demonstrated

3.

lJress code and behavior meet the requirements

organisation
4.

R.tirOitity ir

5.
o.

HospitalSecondary

7
7

of the

O"ro*tr"t"O

tnttiative is demonstrated when is the warranted

F(ecognttion of personal limitation is demonstrated

works is carried out in an organised manner and with attention to

detail so that the desired result is achieved

Works is prioritised effectively

8.

y.

asKS are pursued to completion and within agreed time

limits
(unless overriding circumstances make this imooslibtet
r

ru. HroDrems or potential problems are identified and the appropriate

corrective action taken or solution found
r1. New srtuailon are responded to with flexibilitv and willinoness

7
9

rz. brresstut srtuatrons are handle without undue aoitation

rr.
l.+

tc.

uecrsron are made which demonstrated the ability to

think clearly
and logically and to use discretion

rasKS ano srtuatron are approached with

implications and organisational policy
r

due regard to legal

ne sarery ot the working area is maintained to all times

that
the health and safety of colleagues and ttre puotic so
is not

compromised

ro' r re secrlnry or tne premises is upheld

I

at all times

Otat MlarKs =

,avsrdge I of,al =
Average Performance in

4t
3
o/o=

(Average Total)

164 (100%)

= ll

,o

ot

TO

8%',i%el*lffiee,:*w@ir1FF*]w&:?a:Gt]as:*.s!irr;*1il1
;a*;@i:

Pharmacy Board Malaysia 2011

6.2 Work Effectively as part of a Team

HospitalTertiary

HospitalSecondary

A manner is demonstrated which indicates that due respect

given to the ideas and opinion of colleagues

Advice and criticisms are offered to colleagues in

unlikely to cause offence

3.

manner

Constructive criticism is receive in a positive manner

Average Total =

AveragePerformancein%=(AverageTotal

6.3

undertake Personal and professional Development

ln(00%)= 1f ,O

6.4 CommunicationSkills
i'l

HospitalSecondary

.t::,

.t'

1. A sufficient

command

of the Bahasa wtrt"yri, ,no

Language is demonstrated

3.

English

conversations (in person or over the terephone) are ."rd*t.d

in a manner which demonstrates due regard to confidentiality
and the feelings of the other person
Questioning is used effectively to elicit n...-rry inrurr*ti*

and increase understanding

5.

Responses in conversation are helpful and clear

Body language is appropriate to the situation

Clear, concise and well-structured written material is provided

when required

All responses (whether spoken or written) are t"itoruo

t,o t*
needs
of the recipient

8. A clear, porite and herpfur terephone manner i, o"n.'onJ[6

9. complaints or demands are responded to in a p.r,t" ,.rr*
An appropriately assertive manner is used when unreasonable
demands or complaints are made

Total Marks=
Average Total=

Average Performance in %= (Average

6.5

i@

40 (oo%r

-- guo %

PRP Personal Assessment Average performance

ait*.1t&41:r,*,&#*:*:*i*:rtai.4,:*ui4r';n.:;rti!rri';!..5.:.ili!;:;r:
rr:

.!i i!

i,,

Pharmacy Board Malaysia 2011

APPRAISAL PRP
1.

MAKTUMAT PRP

1.1
L.2
1.3
L.4
2.

NO. PENDAFTARAN PRP:6708

TEMPAT LATIHAN: HOSPITAITEIUK TNTAN

MARKAH BUKU tOG DAN PERSONATASSESSMENT

BIL.
1

2
3

4
5

5
7
8
9

NAMA PENUH: HEMAA/P KRTSHNAN

NO.K/P:890704-08-5234

1600,/0

DAN KE ATAS)

NAMA SEKSYEN
Outpatient Pharmacv Seruices
ln-patient Pharmacy Services
Drugs and Poisons lnformation Services
Manufacturing and Prepacking
lnventory / Store Management
Parenteral Nutrition / lntravenous Additive Services*
Ward Pharmacy Practice

69.23
75.00
75.00
70.80
87.50
85.00

Oncology Pha rmacy Services*

Clinical Pharmacokinetic Services*

82.50
83.30

MARKAH (%)

77.O8

Sekiranya sesebuah hospital tidak menyediakan perkhidmatan yang bertanda *, maka

PRP perlu ditempatkan di unit-unit yang lain mengikut ketetapan Ketua Pegawai
Farmasi

MARKAH PURATA

78.38

PRP PERSONAI ASSESSMEruT AVERAGE PERFORMANCE

10
LT

12
13

Demonstrate a Professional Approach

Work Effectively as Part of a Team
Undertake Personal and Professional Development
Communication Skills

MARKAH PURATA

75.00

7s.00
83.33
80.00
78.33

PRINCIPAL PRECEPTOR

MASTER PRECEPTOR

Tandatangan:

Tandatangan:

Cop Nama dan Jawatan:

ZAWIAH BT ZAINAL
Peqawai Farmasi Gred U5a
Jabatan Farma6i

Hcpitd rehk lnbn

Tarikh: zr1

tt,l/

SnJI ruu-# v{nw$utr.r

s HAqRr
Timbalan Pengarah Kesihatan illegeri
(Fannasii
Bahagian PefthiCmatan Farrrrasi
Jabatan Kesihatan Negeri Perak

Tarikh: 3o /1a I zurV

BORANG PERMOHONAN PENEMPATAN SELEPAS TAMAT LATIHAN SISWAZAH

(Perlu dihantar 2 bulan sebelum tamat latihan)
,.f
Ketua Setiausaha
Kementerian Kesihatan Malaysia
Bahagian Sumber Manusia
Cawangan Pengurusan dan Profesional
Aras 9, Blok 87, Parcel E
62590

PUTRAJAYA

Melalui : Saluran Tertentu

Tuan"

Permohonan Penempatan Pegawai Farmasi Gred U41 Yang Telah Tamat Menjalani Latihan Siswazah
Sub Seksyen 6A(2) Akta Pendaftaran Ahli Farmasi 195L

Kn tg+f.)FN
seorang war.ganegara Malaysia mernohon
PenemPatan setelah tamat menjalani latihan siswazah sebagai seorang Pegawai Farmasi Lantikan
Provisional (Pendaftaran Bersyarat) seperti yang termaktub cli dalam Sub Seksyen 64(2) Akta

U rnD

saya

I P

Pendaftaran Ahli Farmasi 1951.

Butir-butir laniut mengenai diri saya adalah seperti berikut

Penuh l-,-efnA Af P tr& %r^lA'Nr

a) Nama

e9o?oF-.

b) No. Kad Pengenalan:

| tlf 7 I Mef

c)

Tarikh Ldntu

ci)

fantina : x-tr*laki

d*623F

Tempat Lahir:

TELuk- AI|AN

Perempuan

e)Taraf Perkahwinan:*Bujang

/ @

(]ika telah berkahwiru sila sertakan salinan sijil perkahwinan yang telah disahkan)

f) AlamatTempatTinggalsekarang.

Lol l-oOS BnU 6/ 441-frN ln+te&nag

LELA
t e6()0 O -fetrtlQ, tN-f AN
.

s) No. Fail
h)

KKP:

(diisi oletr Kementerian Kesiiratan sahaja - no fail personel)

Butir-butir Keluarga :
i)
Nama * isteri/ suami

ii)

Pekerjaan:

iii)
iv)

Bekerja di sektor

Alamat Tempat Bekerja

v)

Bilangan anak yang tinggal bersama

: * Kerajaan /

Bersekolah

Tidak bersekolah

Badan Berkanun

Swasta

:I
:I
:I

]
]
]

orang

orang
orang

Butir-butir mengenai Latihan Siswazah (pRp) :

Tempat Latihan
tfos?tTq
:

J.

a)
b)
c)
4.

Tarikh Mula

Larihan t

Tarikh Tamat

Latihan

L 'fe,UUL fNThN
4 lrcvErhBerl I zl,le

,.t

** Tempat Pilihan
bertugas di Negeri/Institusi Sahaja:
Keutamaan
Alasan
(Sila sertakan clokumen sokongan yang_ciisahkan jika acla)

i)

lbtf

ii)

Rtr,q<

fiogp 6uN6ei

iii)

5.

zu

BL(L7U

Saya mengaku bahawa kenyataan yang di atas adalah benar.

Tarikh:

Tandatangan pemohon

l.t*/

(*potong bagi yang tidak berkenaan)

PENGESAHAN DARIPADA KETUA
IABATAN FARMASI

ftTSffff ilJ:'t"",.-#tffi1;l|;Tff "t""t-"tfl"niru)iU*tivangciisebutka^

Iaw atan yang diduduki oleh pegawai ini sewaktu Latihan siswazah adalah

Jawatan Asal Hospital / Institusi Ini

Jawatan Yang Berasal Dari ..,........

Tand.atangan

q-1/

.......(nyatakan tempat)

gr

fAtNAL -

ZAWI$
Nama KetualabatanHrmasiTempatLatihan,,;a;iFarmasiGr4USa

I611;","Jt

Plt+'

--*'f#i"rlffi.

Nota: *

Penempatan pegawai akan dibuat berdasarkan keperluan perkhictnatan. pilihan

pe.ernpata. berga.tung
sekiranya terclapat kekosongan jawatan yang ciiperuntukkan
bagi pegawai Farrnasi (Berciaftar penuh) rli

sesebuah tenpat.

Penempatan FRP akan dibuat kepada peringkat NEGERI

dan INSTITUSI sahaja (Institusi : HKL, BpFK
atau Ibu Pejabat KKM)

s.k.
1.

Timbalan Pengarah (pengurusan Farmasi)

Bahagian Perkhidmatan Farmasi
Kementerian Kesihatan Malaysia

fimbalan Pengarah Kesihatan Negeri (Farmasi)/

Ke tu a Pe gawa i Farma s i HK L/p pUI\4/p pU KI\4/HU S M