Reappointment Peer Review Applicant Name: Specialty: How long have you known him/her? What is your relationship to him/her? How often do you see or talk to him/her? TO THE BEST OF YOUR KNOWLEDGE, PLEASE RATE THIS APPLICANT’SMedical/Clinical Knowledge(Required)SuperiorGoodFairPoorNo KnowledgeTechnical and Clinical Skills(Required)SuperiorGoodFairPoorNo KnowledgeClinical Judgment(Required)SuperiorGoodFairPoorNo KnowledgeInterpersonal Skills(Required)SuperiorGoodFairPoorNo KnowledgeCommunication Skills(Required)SuperiorGoodFairPoorNo KnowledgeCommunication Skills(Required)SuperiorGoodFairPoorNo KnowledgeProfessionalism(Required)SuperiorGoodFairPoorNo KnowledgePROFESSIONAL BEHAVIORWere the applicant's practice patterns acceptable and did they conform with high standards of professional conduct?(Required) Yes No Did the applicant behave in an ethical and moral manner while at your facility?(Required) Yes No Did the applicant behave in an ethical and moral manner while at your facility?(Required) Yes No To your knowledge, has the applicant been in good physical condition?(Required) Yes No To your knowledge, has the applicant been in good mental health?(Required) Yes No To your knowledge, has the applicant ever shown signs of any behavior, drug or alcohol problems?(Required) Yes No To your knowledge, has the applicant ever been convicted of a crime, other than a minor traffic violation?(Required) Yes No To your knowledge, has the applicant been involved in any professional liability suits including cases brought, pending, settled or decided)?(Required) Yes No Comments:Your Name First Last Signature I agree that the above is true to the best of my knowledge.Date MM slash DD slash YYYY Email PhoneYour Title:
