ALLIED HEALTH PRACTITIONERS

PROFESSIONAL REFERENCE
CONFIDENTIAL EVALUATION OF APPLICANTS
Professional evaluation concerning ______________________________________________________________
Last First Middle
Reference provided by:
___________________________________________ _____________________________________________
Name (print) Signature ate
___________________________________________ _____________________________________________
!ospital"#rgani$ation Name %elep&one Number
___________________________________________ _____________________________________________
Street 'ddress (ity State )ip
Please ans*er all +uestions based on your personal ,no*ledge and direct observations- .our candor *ill be greatly appreciated- .our
ans*ers *ill be confidential/ e0cept as is necessary for accomplis&ing t&e credentialing process/ or for any related due process
procedures- 1f you need additional space for any +uestion/ you may attac& an additional s&eet(s)-
I. RELATIONSHIP OR REFERENCE SOURCE OF APPLICANT
2- !o* long &ave you ,no*n t&e applicant3 ______________________________________________
4- (&aracter of ac+uaintance3 ((&ec, one) ___ (lose ___ Fre+uent ___ (asual ___ 1nfre+uent
5- !o* muc& time &ave you actually spent in close professional association *it& t&is applicant3
____ .ears _____ Mont&s
6- !o* long &as it been since you *ere closely associated *it& t&e applicant3
____ 1 am still closely associated *it& t&e applicant-
____ 1t &as been _____ years and"or _____ mont&s since 1 &ave been closely associated *it& applicant-
6- 1n *&at capacities"setting &ave you been associated *it& t&e applicant3 (i-e- office/ &ospital/ program director)
________________________________________________________________________________
II. PROFESSIONAL KNOWLEDGE, SKILLS AND ATTITUDE
2- Please rate t&e follo*ing:
70cellent 8ood Fair Poor No 1nfo
Fundamental clinical ,no*ledge
%ec&nical s,ills
(linical 9udgement
%&oroug&ness in Patient (are
1nterpersonal relations&ips/ including
communication s,ills *it& patients and staff
:udgement in recogni$ing &is"&er o*n
responsibilities and duties in relation to t&eir
competency
'd&erence to rules and regulations/ policies and
procedures; fulfillment of medico<administrative
duties
Please comment on Poor or Fair ratings on separate s&eet-
_________________________________________________________ ______________________
Signature"%itle ate