Applicant Reference Form PDF Download Applicant Reference Form v2 Applicant Name * First Applicant Last Name * Last Your Name * First Your Last Name * Last Title * Speciality How long have you known the applicant? * With what frequency and how are you acquainted with the applicant (check all that apply) * Medical business/professional associate Postgraduate training Specialty peer Referral source Daily Weekly Monthly To your knowledge, has the applicant ever been subject to any disciplinary action regarding their professional performance? * No Yes To your knowledge, is there any history of unprofessional conduct? * No Yes To your knowledge, has the applicant ever displayed any problematic behavior toward peers, staff or patients and/or families? * No Yes To your knowledge, has the applicant displayed possible dependence on drugs or alcohol which might affect their ability to perform professional and medical staff duties? * No Yes To your knowledge, does the applicant have any physical/mental conditions that would, in your opinion, impair their ability to practice medicine? * No Yes To your knowledge, has the applicant’s medical license, drug license or clinical privileges ever been reduced, suspended or revoked? * No Yes To your knowledge, has the applicant ever been charged with a felony? * No Yes To your knowledge, are there any cases resulting in litigation involving this applicant? * No Yes If you checked yes to any of the questions above, please comment here: Patient Care * Excellent Good Fair Unsatisfactory No Knowledge Provides care with compassion * Excellent Good Fair Unsatisfactory No Knowledge Provides clinically appropriate care * Excellent Good Fair Unsatisfactory No Knowledge Considerate of patient’s family/friends * Excellent Good Fair Unsatisfactory No Knowledge Availability/Punctuality * Excellent Good Fair Unsatisfactory No Knowledge Medical Knowledge * Excellent Good Fair Unsatisfactory No Knowledge Basic medical/clinical knowledge * Excellent Good Fair Unsatisfactory No Knowledge Knowledge in specialty * Excellent Good Fair Unsatisfactory No Knowledge Technical skills * Excellent Good Fair Unsatisfactory No Knowledge Appropriate use of resources * Excellent Good Fair Unsatisfactory No Knowledge Practice - Based Learning & Improvement * Excellent Good Fair Unsatisfactory No Knowledge Medical knowledge is current * Excellent Good Fair Unsatisfactory No Knowledge Timely, appropriate use of consultants * Excellent Good Fair Unsatisfactory No Knowledge Interpersonal & Communication Skills * Excellent Good Fair Unsatisfactory No Knowledge Overall communication * Excellent Good Fair Unsatisfactory No Knowledge Verbal & written English fluency * Excellent Good Fair Unsatisfactory No Knowledge Rapport with patients * Excellent Good Fair Unsatisfactory No Knowledge Communication with peers * Excellent Good Fair Unsatisfactory No Knowledge Communication with administrative staff * Excellent Good Fair Unsatisfactory No Knowledge Ability to work with healthcare team * Excellent Good Fair Unsatisfactory No Knowledge Appropriate record - keeping * Excellent Good Fair Unsatisfactory No Knowledge Professionalism * Excellent Good Fair Unsatisfactory No Knowledge Ethical standards of treatment * Excellent Good Fair Unsatisfactory No Knowledge Maintains patient confidentiality * Excellent Good Fair Unsatisfactory No Knowledge Maintains responsibility for patients * Excellent Good Fair Unsatisfactory No Knowledge Sensitive to diversity * Excellent Good Fair Unsatisfactory No Knowledge Upon review of the applicant’s Request for Privileges and based on personal knowledge and observation, I believe the applicant possesses the qualifications and skills necessary for the position requested. All Some None I thereby: * recommend without reservation. recommend with the following reservations do not recommend based on the following Reason Signature signature keyboard Clear If you are human, leave this field blank. Submit
