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 This field is required This field needs to be a valid value Position This field is required This field needs to be a valid value Reference Name This field is required This field needs to be a valid value Reference Position This field is required This field needs to be a valid value Reference Contact Information This field is required This field needs to be a valid value How many years have you been associated with the provider? This field is required This field needs to be a valid value In what capacity? Colleague Training Director/Attending Supervisor Other This field is required If 'Other,' please specify. List N/A if not 'other.' This field is required This field needs to be a valid value Describe the setting in which you observed the provider work. This field is required Is your clinical contact with the provider recent (within the last two years)? Yes No This field is required Does the provider know his/her limitations and refers or consults properly? Yes No This field is required Do you have any reason to believe the provider would pose a risk to patients? Yes No This field is required Are you aware of any investigations or disciplinary actions or problems related to his/her professional competence? Yes No This field is required Are you aware of any issues that may affect the provider’s work? Yes No This field is required Would you feel comfortable with the provider treating you or a member of your family? Yes No This field is required Hypothetically, would you hire the provider? Yes No This field is required If 'No', please explain why. If yes, please list 'N/A.' This field is required What are the provider’s strongest characteristics? This field is required What weak or negative aspects are you aware of in the provider’s performance? This field is required 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 = Poor 2 = Average 3 = Good 4 = Excellent N/A = Not Applicable This field is required Medical knowledge 1 = Poor 2 = Average 3 = Good 4 = Excellent N/A = Not Applicable This field is required Professional competence 1 = Poor 2 = Average 3 = Good 4 = Excellent N/A = Not Applicable This field is required Professional appearance 1 = Poor 2 = Average 3 = Good 4 = Excellent N/A = Not Applicable This field is required Patient rapport 1 = Poor 2 = Average 3 = Good 4 = Excellent N/A = Not Applicable This field is required Colleague rapport 1 = Poor 2 = Average 3 = Good 4 = Excellent N/A = Not Applicable This field is required Ability to follow rules/procedures 1 = Poor 2 = Average 3 = Good 4 = Excellent N/A = Not Applicable This field is required