Form 0917-0009 Peer Reference Form

PROFESSIONAL REFERENCE – INDIAN HEALTH SERVICE

Applicant Name: «FormalNameWithDegree» Date:­­­­­ August 2, 2023

(The reference form must be completed by a peer from your own profession; e.g., reference for a FNP from a FNP)

Reference Name: «RS_Name»

Please answer the following questions based on your personal knowledge as a peer of this practitioner. *Note: If your response to any of the following is "below average", please supply a written explanation on a separate sheet of paper.

EVALUATION	Above Average	Satisfactory	Below Average*	Not Applicable
PATIENT CARE/MEDICAL & CLINICAL KNOWLEDGE
Basic Medical Knowledge
Professional Judgment
Clinical/Technical Skills
Positive Patient Outcome/Results
Appropriate Utilization of Resources
Appropriate Use of Consultations
Appropriate Use of Medication
INTERPERSONAL & COMMUNICATION SKILLS WITH:
Patients
Superiors/Administrations
Colleagues/Peers/Clinical Support Staff
Ability to Understand, Speak, Read and Write English
PROFESSIONALISM
Availability/Responsiveness
Ethical Conduct
Emotional Stability
Moral Character
SYSTEMS-BASED PRACTICE
Medical Record Timeliness
Compliance with Medical Staff Bylaws, MS Policies
PRACTICE-BASED LEARNING & IMPROVEMENT
Investigates and evaluates patient care practices
Appraise and assimilates scientific evidence
Improves the practice of medicine

1. How long have you known the practitioner? ______________________

2. What is your relationship to the practitioner?_____________________________________

3. When was the last time you observed the practitioner provide patient care ? ____________ Direct Observation? __________ Indirect Observation? ____________

4. To your knowledge, does this applicant have any medical malpractice suits? ( ) Yes ( ) No If yes, please provide an explanation on a separate sheet of paper.

5. Would you hire/rehire this practitioner? ( ) Yes ( ) No If no, please provide an explanation on a separate sheet of paper.

6. Would you be comfortable having your friends or family treated by this applicant? ( ) Yes ( ) No If no, please provide an explanation on a separate sheet of paper.

7. To your knowledge, does the practitioner have any physical or mental impairments that could possibly affect his/her ability to exercise requested privileges? ( ) No ( ) Yes If yes, please provide a full explanation on a separate sheet of paper.

8. To your knowledge, does the practitioner suffer from alcohol or drug abuse or dependency? ( ) No ( ) Yes If yes, please provide a full explanation on a separate sheet of paper.

9. As a peer of the above named practitioner, I: (Please select one below):

____ Recommend as Qualified and Competent to perform the attached privileges.

____ Recommend with Reservation (please provide a full explanation on a separate sheet of paper)

____ Do not Recommend (please provide a full explanation on a separate sheet of paper)

Signature: __________________________________________________________ Date: _____________________

Title: ______________________________________________________________ Phone: ___________________

Please return the form DIRECTLY to the Medical Staff Office, we cannot accept from a 3^rd party.

Return to: «FacilityName» Facility Address/secure email/fax «Image:File_Privilege»