1562.docx
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- Solicitation ER Physician Assistant
- Solicitation number
- FA5587-12-R-0011
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This form is mandatory and must be completed and returned with proposal.
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Other files
| File | Type | Posted |
|---|---|---|
| Solicitation Amendment ER PA 12 Aug 12.pdf | ||
| Credentials Checklist for Incoming Contracted Providers.doc | DOC document | |
| AF Form 22 Revised 2010.doc | DOC document | |
| ER Physician Assistant 6 Jul 12.doc | DOC document | |
| AF_Form_1540_final-2004 1 .rtf | RTF text file |
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CREDENTIALS EVALUATION OF HEALTH CARE PRACTITIONERS
AUTHORITY: Title 10, U.S.C. Chapter 55 and Section 8067 and 8012.
PRINCIPAL PURPOSE(S): To evaluate each practitioner’s formal education, training, clinical experience, and evidence of physical, moral and ethical capacities and to assist the Credentials Committee in making recommendations with regard to the practitioner’s competence to treat certain conditions and perform certain medical procedures.
ROUTINE USE(S): Information may be released to government boards or agencies or professional societies or organizations if needed to license or monitor professional standards of health care practitioners. It may also be released to civilian medical institutions or organizations where the practitioner is applying for staff privileges during or after separating from the service.
DISCLOSURE IS VOLUNTARY: However, failure to provide information may result in the limitation or termination of clinical privileges.
I. TO BE COMPLETED BY PRACTITIONER
1. NAME (Last, First, Middle Initial)
2. SSN
| RELEASE OF LIABILITY |
| I hereby release from liability all officials of the United States Air Force including all representatives of the hospital and its medical staff for their acts |
performed in good faith and without malice in connection with evaluating or action concerning my application and my credentials and qualifications. I here-by release from liability any and all individuals and organizations who in good faith and without malice, provide any and all information to officials of the United States Air Force, including medical facility officers, or to the authorized medical staff representatives, concerning my professional practice, competence, ethics, character and other qualifications for staff appointment and clinical privileges, and hereby consent to the release of any and all such information.
| 3. SIGNATURE |
| 4. DATE |
II. TO BE COMPLETED BY EVALUATOR
| 5. NAME OF INSTITUTION WHERE THE ABOVE PRACTITIONER PRACTICED | |
| 6. | DATES AT INSTITUTION |
| FROM |
TO
7. STATUS OF PRACTITIONER (Staff, Resident, etc.)
8. SPECIALTY OR SPECIALTIES PRACTITIONER HAD PRIVILEGES IN AT THIS FACILITY
9. The following evaluation is based in demonstrated performance compared to that reasonably expected of a practitioner at his or her level of training, experience and background:
PERFORMANCE
(Mark “x” in the appropriate block for each item listed)
| POOR |
| FAIR |
| GOOD |
| SUPERIOR |
| NOT |
OBSERVED
| A. BASIC PROFESSIONAL KNOWLEDGE |
| B. PROFESSIONAL JUDGMENT |
| C. SENSE OF RESPONSIBILITY |
| D. ETHICAL CONDUCT |
| E. COMPETENCE AND SKILL |
| F. COOPERATIVENESS, ABILITY TO WORK WITH OTHERS |
| G. APPEARANCE |
| H. HISTORY AND PHYSICAL EXAM |
| I. RECORD KEEPING |
| J. CASE PRESENTATIONS |
| K. PATIENT MANAGEMENT |
| L. PRACTITIONER-PATIENT RELATIONS |
| M. ABILITY TO WRITE AND SPEAK ENGLISH |
| N. PARTICIPATION IN STAFF AND COMMITTEE ACTIVITIES |
| O. REGULARLY OBTAINED CONSULTATIONS WHEN NEEDED |
| 10. If the answer to any of the following questions is “YES” please give full details in the Remarks Section on reverse. If additional space is needed, continue on a separate sheet of paper and attach to this form. Be sure to identify item by number. |
| To your knowledge has the applicant: |
| YES |
| NO |
| YES |
| NO |
| A. EVER HAD HIS OR HER LICENSE TO PRACTICE IN ANY | JURISDICTION LIMITED, SUSPENDED OR REVOKED? |
| G. EVER BEEN A DEFENDANT IN A FELONY CASE? |
| B. EVER BEEN REFUSED MEMBERSHIP ON A | MEDICAL | STAFF? |
| H. HAD ANY SIGNIFICANT MEDICAL OR MENTAL HEALTH | ||
| PROBLEMS WHICH COULD AFFECT WORK | PERFORMANCE? |
| C. EVER HAD A REQUEST FOR SPECIFIC PRIVILEGES |
| DENIED OR GRANTED WITH STATED LIMITATIONS? |
| I. EVER BEEN A DEFENDANT OR THE SUBJECT |
| OF A MALPRACTICE ACTION? |
| D. EVER HAD PRIVILEGES AT ANY HOSPITAL | |
| SUSPENDED, LIMITED, OR REVOKED? | |
| IF “YES,” WAS THE MATTER: |
| E. EVER HAD NARCOTIC REGISTRATION | |
| (1) SETTLED PRIOR TO FINAL COURT ACTION? |
SUSPENDED OR REVOKED?
| (2) JUDGMENT RENDERED BY COURT? |
| F. EVER BEEN ARRESTED OR TREATED FOR DRUG | |
| (3) DEFENDANT FOUND LIABLE? |
OR ALCOHOL ABUSE?
| (4) MATTER STILL PENDING? |
AF FORM 1562 PREVIOUS EDITION IS OBSOLETE
DEC 84
11. COMPLETE IF PRIVILEGE LIST REVIEWED
A. REVIEWED PRIVILEGE LIST FROM
|_| AIR FORCE RECRUITING PERSONNEL
|_| PRACTITIONER’S AIR FORCE CREDENTIALS FILE
| |_| OTHER CIVILIAN (Describe in “Remarks “) | |
| B. UPON REVIEW OF THE PRIVILEGE LIST, DO YOU HAVE ANY | |
| RESERVATIONS ABOUT THE PRACTITIONER EXERCISING ALL | |
| PRIVILEGES LISTED? | |
| |_| YES (If yes, please explain in “Remarks.”) | |_| NO |
12. NUMBER OF YEARS YOU HAVE KNOWN THE APPLICANT
13. BEST TELEPHONE NUMBER TO CONTACT YOU
14. REMARKS (Please add any other information you think appropriate in evaluating this applicant)
15. NAME AND TITLE OF EVALUATOR
| 16. SIGNATURE |
| 17. DATE |
REVERSE OF AF FORM 1562, DEC 84
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