Physician Evaluation Form Page 3

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Physician Evaluation Form
(Example Continued)
RE: (Candidate Name)
CORRECTIVE ACTION
To your knowledge, during the time known to you or as documented in your
hospital’s or institution’s records by others in authority:
Has this applicant ever been subject to any investigation or disciplinary action
(including but not limited to the following): admonition, reprimand, suspension or
termination by a licensing authority, Board of Trustees, or Medical Staff?
1. For unethical conduct
YES _____
NO _____
Unknown _____
2. For any other reason
YES _____
NO _____
Unknown _____
In your opinion, has the applicant ever shown signs of not being able to safely
perform all elements and requirements of his/her clinical privileges?
YES _____
NO _____
Unknown _____
Has/had the applicant ever interrupted his/her medical practice or been unable to
perform all elements of the clinical privileges for which they have applied?
YES _____
NO _____
Unknown _____
RECOMMENDATION(S)
Please indicate your recommendations of this applicant for appointment to the Medical
Staff of (your organization):
I would highly recommend this applicant without reservation.
I would recommend this applicant as qualified and competent.
I do not recommend this applicant.

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