SPONSORING PHYSICIAN EVALUATION FORM for Physician Employed Personnel This form is to be completed by your sponsoring physician while working at (specify Vidant Health Entity) _______________________ and return with the renewal application packet. Physician Employed Personnel: ____________________________________ Title: _____________________________________________________ Sponsoring Physician: ___________________________________________ I am the sponsoring physician of the Physician Employed Personnel and have assessed the following: Exceeds Expectations Substantially Below Fulfills Exceeds Expectations Expectations Expectations Displays thorough Does not Consistently I am the sponsoring physician of the above-named Physician Demonstrates understandings consistently meets and N/A Employed Personnel and have assessed the following: exceptional drive, of duties and demonstrate occasionally motivation, and responsibilities, quality and exceeds the willingness to effectively quantity of work requirements always perform at utilizes skills in knowledge and of the job and the highest levels carrying out activities. established and standards. duties and standards. responsibilities. *Please check the appropriate box* Comments: Have there been any disciplinary actions taken against this person this past year related to the duties within the scope of practice. No Yes If yes, please provide explanation. □ □ Based on personal knowledge and observation, I recommend that this person to continue to practice within their scope of practice at the above designated Vidant Health Entity. No Yes □ □ I have provided this information for use in the physician employed personnel evaluation process at Vidant Health I understand that should I no longer have privileges on the staff of Vidant Health this person will no longer be supervised by me and will not be allowed to work in the hospital in this same capacity. I am fully responsible for all actions of this person while performing his/her duties at Vidant Health as their scope of practice/privileges apply. (page 1 of 2)
SPONSORING PHYSICIAN EVALUATION FORM for Physician Employed Personnel This form is to be completed by your sponsoring physician while working at (specify Vidant Health Entity) _______________________ and return with the renewal application packet. Physician Employed Personnel: ____________________________________ Title: _____________________________________________________ Sponsoring Physician: ___________________________________________ I am the sponsoring physician of the Physician Employed Personnel and have assessed the following: I am the sponsoring physician of the above-named Physician Employed Personnel and have assessed the following: Substantially Exceeds Expectations Demonstrates exceptional drive, motivation, and willingness to always perform at the highest levels and standards. Exceeds Expectations Displays thorough understandings of duties and responsibilities, effectively utilizes skills in carrying out duties and responsibilities. Fulfills Expectations Consistently meets and occasionally exceeds the requirements of the job and established standards. Below Expectations Does not consistently demonstrate quality and quantity of work knowledge and activities. N/A *Please check the appropriate box* Comments: Have there been any disciplinary actions taken against this person this past year related to the duties within the scope of practice. □ No □ Yes If yes, please provide explanation. Based on personal knowledge and observation, I recommend that this person to continue to practice within their scope of practice at the above designated Vidant Health Entity. □ No □ Yes I have provided this information for use in the physician employed personnel evaluation process at Vidant Health I understand that should I no longer have privileges on the staff of Vidant Health this person will no longer be supervised by me and will not be allowed to work in the hospital in this same capacity. I am fully responsible for all actions of this person while performing his/her duties at Vidant Health as their scope of practice/privileges apply. (page 1 of 2)
Sponsoring_physician_evaluation2017.docx