0917-0009 Peer Reference Form

PROFESSIONAL REFERENCE – INDIAN HEALTH SERVICE

Applicant Name: «FormalNameWithDegree» Date:­­­­­ July 25, 2024

Applying for: _________________________Reference Name: «RS_Name» Reference Specialty: <<Specialty>>

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.

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
Current 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. Are you familiar with the practitioner’s actual performance within the past 24 months? ( ) Yes ( ) No If no, please explain last time you observed the practitioner provide care (indirectly or directly).

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. What specialty was the practitioner performing in when you observed their medical knowledge, skills, and abilities? ______

5. Would you hire/rehire this practitioner? ( ) Yes ( ) No If no, please provide an explanation.

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

7. To your knowledge, are you aware of any procedures or privileges you would recommend the practitioner be monitored more closely on? ( ) No ( ) Yes If yes, please identify and provide an explanation.

8. To your knowledge, are you aware if the practitioner is currently engaged in illegal use of legal or illegal substances? ( ) No ( ) Yes If yes, please provide an explanation.

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

____ Recommend as Qualified and Competent to perform privileges associated with the practitioner’s specialty.

____ 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 the peer being evaluated or a 3^rd party.

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

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is [####-####]. This information collection is to be used in verifying an applicant’s credentials to meet agency policy and accrediting body standards. The time required to complete this information collection is estimated to average less than 15 minutes per response, including the time to review instructions, search existing data resources, gather the data needed, to review and complete the information collection. This information collection is required to determine an applicant’s credentials to provide healthcare (IHS IHM 3-1.4 C. (6) h. and [the nature and extent of confidentiality to be provided, if any ( (the Privacy Act, 5 U.S.C. § 552; the Privacy Rule promulgated under the Health Insurance Portability and Accountability Act of 1996 (HIPAA), 45 CFR Part 160 and Subparts A and E of Part 164; the Indian Health Care Improvement Act, 25 U.S.C. § 1675; and the Confidentiality of Substance Use Disorder Patient Records regulations, 42 C.F.R. Part 2)]]. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: Indian Health Service, 5600 Fishers Lane, mailstop: 09E07, Rockville, MD 20857, Attention: Information Collections Clearance Officer