Name of Applicant*Name of Reference*Professional Relationship to ApplicantTraining directorProfessional colleagueMedical staff directorPartnerFor how long have you professionally known the applicantPlease rate the applicant in the following areas1. Patient care (compassionate, appropriate and effective at the treatment of health problems and promotion of health)UnsatisfactorySatisfactoryOutstanding2. Medical knowledge (Both cognitive and clinical application)UnsatisfactorySatisfactoryOutstanding3. Communication Skills (Effective communication with patients, families and other healthcare professionals)UnsatisfactorySatisfactoryOutstanding4. Professionalism (Appropriate behavior and communication)UnsatisfactorySatisfactoryOutstanding5. Practice based learning (Evidence based practice guidelines for improved patient outcomes by nationally recognized agencies, authorities and experts)UnsatisfactorySatisfactoryOutstanding6. System based practice (understanding and utilizing the integrated components of the healthcare system and EMR effectively)UnsatisfactorySatisfactoryOutstandingHealth 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?YesNoIf yes to the previous question, please explainPeer 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* TitleDate Date Format: MM slash DD slash YYYY EmailThis field is for validation purposes and should be left unchanged.
