Perfusion Consultants / Perfusion Partners

RECOMMENDATION / EVALUATION FORM
PERFUSION DEPARTMENT ASSESSMENT

[5] Perfusion Department Assessment
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 performance compared to that reasonably expected for this 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
Scope of Practice: A Scope of Practice (Delineation of Privileges) is attached? ☐ YES ☐ NO I have reviewed the attached Scope of Practice and believe this applicant is qualified to perform the Practice Privileges requested.
Disciplinary Action: To your knowledge has the applicant been the subject of any complaints, disciplinary actions, privileges revoked, suspended, reduced, or denied, either related to clinical competency or behavioral issues?
Physical and Mental Condition: To 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?