Physician Peer Feedback Form
Peer Feedback Form v1
Name of reviewer
The following guidelines are to be used in selecting the appropriate rating:
Implements the highest standards of practice in the effective and timely treatment of all patients regardless
of gender, ethnicity, location, or socioeconomic status.
City, State, Zip code
PEER Feedback for:
Please print full name
of physician being
Please rate the above-named
physician on the six general
competencies as identified bythe
Accreditation Council for Graduate
Medical Education (ACGME) and
the American Board of Medical
Keeps current with research and medical knowledge in order to provide evidence-based care.
Communicates effectively and works vigorously and efficiently with all involved parties as patient advocate and/or consultant.
Assesses medical knowledge and new technology and implements best practices in clinical setting.
Displays personal characteristics consistent with high moral and ethical behavior.
Efficiently utilizes health-care resources and community systems of care in the treatment of patients.
1 2 3 4 5 6
Never Rarely OccasionallyFrequently Always
Please Return Completed Form To Physician For His/Her Confidential Records - Do Not Send to the ABPN