Provider Reference Questionnaire Please enable JavaScript in your browser to complete this form.Applicant Name *LayoutHow long have your known the Applicant? *DatesWhat is your relationship to the applicant? *MentorColleague Supervisor/ManagerOtherPlease explain: *LayoutClinical Knowledge *Very GoodGoodFairPoorNo KnowledgeSurgical Skills (if appropriate) *N/AVery GoodGoodFairPoorNo KnowledgeWork Habits *Very GoodGoodFairPoorNo KnowledgeRelationship with patients *Very GoodGoodFairPoorNo KnowledgeRelationship with hospital staff *Very GoodGoodFairPoorNo KnowledgeProfessional attitude *Very GoodGoodFairPoorNo KnowledgeClinical Competence *Very GoodGoodFairPoorNo KnowledgeEmotional Stability *Very GoodGoodFairPoorNo KnowledgeParticipation in Staff/Committee Activities *Very GoodGoodFairPoorNo KnowledgeRelationship with peers *Very GoodGoodFairPoorNo KnowledgeAbility to work with others *Very GoodGoodFairPoorNo KnowledgeDoes the Applicant regularly obtain consultations when needed? *YesNoNo Knowledge To your knowledge, did the applicant have any restriction of hospital privileges? *YesNoNo Knowledge Comment *Has Applicant's privileges to admit or treat patients ever been suspended or revoked, excepting temporary suspensions for failure to complete medical records? *YesNoNo Knowledge Please provide details *To your knowledge, has the Applicant: Ever been a defendant in a medical malpractice action? *YesNoNo Knowledge How Many Times (if you know)?To your knowledge, has the Applicant: Ever been the subject of disciplinary action by a Licensing Authority, Board of Trustees, or Medical Staff? *YesNoNo Knowledge CommentTo your knowledge, has the Applicant: Ever been a habitual user of D.E.A. classified drugs or alcohol? *YesNoNo Knowledge CommentTo your knowledge, has the Applicant: Ever been a defendant in a felony criminal matter? *YesNoNo Knowledge Nature of Allegation(s) *Please comment as to the appropriateness of the requested privileges sent to you for this applicant would be appreciated. *SUMMARY RECOMMENDATION *I would recommend without reservationsI would recommendI would not recommend this ApplicantSharing evaluation with applicant. *I am willing to have this evaluation shared with the applicantI am not willing to have this evaluation shared with the applicantName *FirstLastTyping your name will be counted as your digital signature. TitleName of FacilityIf we need to contact you for follow up what is your preferred method of communicationPhoneEmailPhone Number *What time is best to contact you? *Email *Submit
