Please answer the following questions to the best of your knowledge in regard to the provider listed in the email. Default Page Provider Reference Form Regarding Position Reference Name Reference Position Reference Contact Information How many years have you been associated with the provider? In what capacity? Colleague Training Director/Attending SupervisorOther If 'Other,' please specify. List N/A if not 'other.' Describe the setting in which you observed the provider work. Is your clinical contact with the provider recent (within the last two years)? YesNo Does the provider know his/her limitations and refers or consults properly? YesNo Do you have any reason to believe the provider would pose a risk to patients? YesNo Are you aware of any investigations or disciplinary actions or problems related to his/her professional competence? YesNo Are you aware of any issues that may affect the provider’s work? YesNo Would you feel comfortable with the provider treating you or a member of your family? YesNo Hypothetically, would you hire the provider? YesNo If 'No', please explain why. If yes, please list 'N/A.' What are the provider’s strongest characteristics? What weak or negative aspects are you aware of in the provider’s performance? Please use the following scale to rate the provider in each of the areas below: 1 = Poor, 2 = Average, 3 = Good, 4 = Excellent, N/A = Not Applicable Clinical skills 1 = Poor2 = Average3 = Good4 = ExcellentN/A = Not Applicable Medical knowledge 1 = Poor2 = Average3 = Good4 = ExcellentN/A = Not Applicable Professional competence 1 = Poor2 = Average3 = Good4 = ExcellentN/A = Not Applicable Professional appearance 1 = Poor2 = Average3 = Good4 = ExcellentN/A = Not Applicable Patient rapport 1 = Poor2 = Average3 = Good4 = ExcellentN/A = Not Applicable Colleague rapport 1 = Poor2 = Average3 = Good4 = ExcellentN/A = Not Applicable Ability to follow rules/procedures 1 = Poor2 = Average3 = Good4 = ExcellentN/A = Not Applicable