Perfusion Consultants / Perfusion Partners

RECOMMENDATION / EVALUATION FORM

[1] Autotransfusionist New Hire
Medical/Clinical Knowledge
Technical/Clinical Skills and Judgement
Knowledge of Procedures and Instrumentation
Communication Skills
Performance of Assigned Duties

Please complete the following evaluation based on demonstrated  job performance compared to that reasonably expected for the position.  Your responses should be based on specific experience, demonstrated performance, and your direct working relationship with the applicant.

Ethics and Conduct
Emotional Stability
Likert Scale
Cooperative Attitude Toward Others
In order to comply with regulatory agency requirements to confirm identity of the applicant, a photograph of the applicant is attached. Are you able to confirm the identity of the applicant by the attached photograph?
To your knowledge has the applicant been the subject of any disciplinary actions, complaints, either related to competency or behavioral issues?
o your knowledge are there any indications of physical or mental disability or conditions, including possible dependence on drugs or alcohol, which would impair his/her professional functioning?