ANNEX
Informed Consent form
Alkan health science business and Technology College for department of pharmacy. A
questioner for assessment of good dispensing practices in private drug stores in Burayu Oromia,
Ethiopia.
Dear everybody, our name is Abdi Desta and Aklilu Kassahun, we are the members of research
project done by Alkan health science business and technology college 5 th year graduate Students.
This study is proposed to assess the good dispensing practices in private drug stores in Burayu
Oromia, Ethiopia. The purpose of this study is to generate valuable information about the topic
for decision makers. I am going to ask some questions in relation to this topic. There is no need
to write your name. No individual response is reported. Your answer is completely confidential.
It is your full right to refuse to answer any or all of the questions. However, your honest response
to these questions helped us to better understand to assess the good dispensing practices in
private drug stores in Burayu Oromia, Ethiopia.
I. The interview will take only about 20 minutes of your time.
At this time do you want to ask us anything about the survey?
May we begin the interview now?
1. If yes, signature__________________, Continue the interview.
2. If no, skip to the next participant by writing reasons for his/her refusal.
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PART II. Socio-demographic Background Information
1. Name of drug store (code) _________
2. What is your age? _________
3. Gender
A, Male B, Female
4. Marital status
A, Married B, Unmarried
5. How many staff is there?
A, 1 B, 2
C, 3 D, more than 3
6. Education level
A, pharmacist C, pharmacy technician
B, druggist D, other
7. Working experience (years) _________
8. Is there telephone service?
A. Yes [Link]
9. Is there electric supply?
A. Yes [Link]
10. Is there refrigerator?
A. Yes [Link]
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PART III: KNOWLEDGE AND EXPERIENCE ON DISPENSING PRACTICE
11. Do you have Good dispensing manual?
A. Yes B. No
12. Which type of Standard reference books do you have?
A. EDL B. STG C. Formulary D. other
13. Do you have list of over the counter (OTC) drugs?
A. Yes B .No
14. Do you update yourself in searching for recent information regarding drugs?
A. Yes B. No
15. If Q14 is yes, which information source did you use?
A. Standard reference books B. Medical and pharmaceutical journals
C. Internet D. Another, (Specify) _________________
16. Do you dispense prescribed drugs after 30 days and controlled drugs after 15days?
A. Yes B. No
17. How often you dispensed prescription drugs without prescription?
A. Always B. Sometimes C. C. Never
18. Have you ever encountered any prescription error?
A. Yes B. No
19. If Q 18 is yes type of error you encountered?
A. Illegible prescription C. Containing drugs which interact
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B. incomplete prescription D. legality problems
E. other, specify_____________
20. What measure have you taken for the prescription error you encountered?
A. dispensed by guess
B. makes correction by communicating with the patient
C. check for reference books (if needed)
D. Communicate with the prescriber back
21. What drug information you mostly provide to patient during dispensing?
_________________________________________________________
22. Do you label?
A. Yes B. No
23. If yes, for which labeling system do you follow when dispensing to illiterate patients?
A. Writing in words and / or numbers. C. No need of labeling, only oral information is
enough
B. use of pictograms D. other, (specify)
24. If yes Q 22for which type of patients do you write labels on the dispensed drugs?
A. Literate B. Illiterate C. Both
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PART IV. PATIENT KNOWLEDGE
No. Questions YES NO
1 Do you remind the name of drug?
2 Do you know the dose of the drug?
3 Do you know the duration of treatment?
4 Do you know the frequency of administration?
5 Do you know the possible side effect?
6 Do you get any advice regarding the proper use of
your medicines?