Candidate Name *
Facility *
Department *
Title
DR
MISS
MR
MRS
MS
Your Name *
Last Name *
Email Address *
Your position *
Direct contact number *
Relationship to candidate - I am a ... *
-- Please select --
Supervisor
Peer
Subordinate
Today's date *
When was your most recent professional contact with this practitioner? *
How long did you work with the candidate? *
Clinical - Knowledge base. Demonstrates adequate knowledge of basic and clinical sciences *
-- Please select --
Requires further development
Consistent with level of appoinment
Performance better than expected
Performance exceptional
N/A or Not observed
Clinical judgement/decision making skills. Applies knowledge base and clinical findings in organising, synthetising and acting on information. *
-- Please select --
Requires further development
Consistent with level of appoinment
Performance better than expected
Performance exceptional
N/A or Not observed
Emergency skills. Acts effectively, and when appropriate acknowledges own limitations and seeks help *
-- Please select --
Requires further development
Consistent with level of appoinment
Performance better than expected
Performance exceptional
N/A or Not observed
Procedural skills. Performs procedures competently. *
-- Please select --
Requires further development
Consistent with level of appoinment
Performance better than expected
Performance exceptional
N/A or Not observed
Patient and Family. Interacts effectively and sensitively with patients and families/care givers. *
-- Please select --
Requires further development
Consistent with level of appoinment
Performance better than expected
Performance exceptional
N/A or Not observed
Medical Records/Clinical Documentation. Provides clear, comprehensive and accurate records. *
-- Please select --
Requires further development
Consistent with level of appoinment
Performance better than expected
Performance exceptional
N/A or Not observed
Professional Responsibility. Demonstrates, appropriate attitudes and behaviours, including punctuality, reliability, honesty and professional appearance. *
-- Please select --
Requires further development
Consistent with level of appoinment
Performance better than expected
Performance exceptional
N/A or Not observed
Time management skills. Organises and prioritises tasks to be undertaken. *
-- Please select --
Requires further development
Consistent with level of appoinment
Performance better than expected
Performance exceptional
N/A or Not observed
Are you aware of what steps he/she has taken to stay abreast of new developments in the field of professional practice? (e.g. participate in continuing medical education)? *
Are you aware of any impairment that detrimentally affects or is likely to affect this practitioner’s capacity to practice? *
-- Please select --
Yes
No
Are you aware of any complaints, disciplinary, or legal action against this medical practitioner? *
-- Please select --
Yes
No
How comfortable would you feel having this medical practitioner treat a member of your family? *
Please give specific examples of where this candidate could have PERFORMED BETTER *
Please give specific examples of where this candidate EXCEEDED EXPECTATIONS *
What would you say motivates her/him? *
Would you accept this candidate in your department again? *
-- Please select --
Absolutely
Yes, with some hesitation
No
Would you recommend this candidate to another department? *
-- Please select --
Yes
No
Any further comments?
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