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  2. 2015
  3. July
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Your Name(The assessor):
   
 
 
 
Position:
   
 
 
 
Resident Name:
   
 
 
 
How would you describe your professional relationship to the physican?
 
Intern
 
Consultant
 
Other
 
 
 
How well do you know this physician?
 
Not at all
 
Not well
 
Somewhat
 
Well
 
very well
 
 
Choose any of the appropriate options listed below as per the given category.
Among the Worst(1) Bottom Half(2) Average(3) Top Half (4) Among the Best(5) Unable to Assess
1. Maintains confidentiality of patients.
2.Recognises boundaries when dealing with other physicans.
3.Recognises boundaries when dealing with other health care professionals.
 
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