Phoenix Integrated Surgical Residency

Today's Date:
Your First Name:
Your Last Name:
Your Email Address:
Name of resident on behalf of whom you are filling out this survey:
1. How familiar are you with the quality of this physicians clinical practice? (1 = extremely well, 2 = very well, 3 = well, 4 = not so well, 5 = not at all)	1 2 3 4 5
2. Name of practice
3A. Please evaluate the physician in regard to Patient Care. Physician practices in a manner that meets your expectations for a peer. (1 = always, 3 = sometimes, 5 = never, UTE = unable to evaluate)	1 2 3 4 5 UTE
3B-a. Please evaluate the physician in regard to Medical Knowledge. Physician’s fund of knowledge is appropriate for their level of experience. (1 = always, 3 = sometimes, 5 = never, UTE = unable to evaluate)	1 2 3 4 5 UTE
3B-b. Please evaluate the physician in regard to Medical Knowledge. Physician uses evidence based medicine effectively. (1 = always, 3 = sometimes, 5 = never, UTE = unable to evaluate)	1 2 3 4 5 UTE
3C-a. Please evaluate the physician in regard to Interpersonal/Communication Skills. Physician effectively builds rapport with patients, peers and staff. (1 = always, 3 = sometimes, 5 = never, UTE = unable to evaluate)	1 2 3 4 5 UTE
3C-b. Please evaluate the physician in regard to Interpersonal/Communication Skills. Physician communicates factual material effectively. (1 = always, 3 = sometimes, 5 = never, UTE = unable to evaluate)	1 2 3 4 5 UTE
3D. Please evaluate the physician in regard to Professionalism. Physician demonstrates professionalism expected of a peer (altruistic, truthful, ethical, respectful, responsible, self-aware). (1 = always, 3 = sometimes, 5 = never, UTE = unable to evaluate)	1 2 3 4 5 UTE
3E. Please evaluate the physician in regard to System Based Practice. Physician uses the medical care system effectively in advocating for patients. (1 = always, 3 = sometimes, 5 = never, UTE = unable to evaluate)	1 2 3 4 5 UTE
3F. Please evaluate the physician in regard to Practice Based Learning and Improvement. Physicians demonstrates ability to evaluate own needs and improve outcomes. (1 = always, 3 = sometimes, 5 = never, UTE = unable to evaluate)	1 2 3 4 5 UTE
4. This physician's quality of care meets your expectations for excellent quality of care. (1 = always, 2 = usually, 3 = sometimes, 4 = once in a while, 5 = never, UTE = unable to evaluate)	1 2 3 4 5 UTE
5. Please provide written comments on this physician.