Name of Applicant* Name of Reference* Professional Relationship to ApplicantTraining directorProfessional colleagueMedical staff directorPartnerFor how long have you professionally known the applicant Please rate the applicant in the following areas1. Patient care (compassionate, appropriate and effective tat the treatment of health problems and promotion of health) Unsatisfactory Satisfactory Outstanding 2. Medical knowledge (Both cognitive and clinical application) Unsatisfactory Satisfactory Outstanding 3. Communication Skills (Effective communication with patients, families and other healthcare professionals) Unsatisfactory Satisfactory Outstanding 4. Professionalism (Appropriate behavior and communication) Unsatisfactory Satisfactory Outstanding 5. Practice based learning (Evidence based practice guidelines for improved patient outcomes by nationally recognized agencies, authorities and experts) Unsatisfactory Satisfactory Outstanding 6. System based practice (understanding and utilizing the integrated components of the healthcare system and EMR effectively) Unsatisfactory Satisfactory Outstanding Health status: Do you know of any physical or mental condition that could affect the applicants ability to exercise clinical privileges requested in their specialty area or would require accommodation to exercise those privileges safely and competently? Yes No If yes to the previous question, please explain Peer recommendation (check one) I recommend the applicant without reservation. I recommend the applicant with the following reservations. I do not recommend the applicant. Please insert comments regarding reservations hereName* Email* Title Date MM slash DD slash YYYY NameThis field is for validation purposes and should be left unchanged.
