Applicant Reference Form

Applicant Reference Form v2
Ethical standards of treatment
Overall communication
Medical knowledge is current
Basic medical/clinical knowledge
Provides care with compassion
Maintains patient confidentiality
Verbal & written English fluency
Timely, appropriate use of consultants
Knowledge in specialty
Provides clinically appropriate care
Maintains responsibility for patients
Rapport with patients
Technical skills
Considerate of patient’s family/friends
Communication with peers
Sensitive to diversity
Appropriate use of resources
Communication with administrative staff
Ability to work with healthcare team
Appropriate record - keeping
With what frequency and how are you acquainted with the applicant (check all that apply)
To your knowledge, has the applicant ever been subject to any disciplinary action regarding their professional performance?
To your knowledge, is there any history of unprofessional conduct?
To your knowledge, has the applicant ever displayed any problematic behavior toward peers, staff or patients and/or families?
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?
To your knowledge, does the applicant have any physical/mental conditions that would, in your opinion, impair their ability to practice medicine?
To your knowledge, has the applicant’s medical license, drug license or clinical privileges ever been reduced, suspended or revoked?
To your knowledge, has the applicant ever been charged with a felony?
To your knowledge, are there any cases resulting in litigation involving this applicant?
Patient Care
Medical Knowledge
Practice - Based Learning & Improvement
Interpersonal & Communication Skills
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.
I thereby:
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