Community Health Center
Clinician Fitness Verification Form (INITIAL)
As part of ______’s overall credentialing process (a component of the Quality Management program), each clinician’s fitness for employment must be assessed by the Department Director, CEO and approved by the Community Board of Directors. The issues below will enable the Department Director, CEO and Board to make appropriate decisions RE: appointment to the behavioral health, medical or dental staff.
CLINICIAN’S NAME: ______
- Licensure Verified: (Initials of Verifier: _____) State / Period of Licensure: Date of Verification: Source:
- Education/Training Verified: (Initials of Verifier: _____)
Date of Verification: Source(s):
3. Experience Verified/References Received: (Initials of Verifier: _____) 1st (Date Rec’d: ______):
2nd (Date Rec’d: ______)
3rd (Date Rec’d: ______):
4. DEA # Verified (Initials of Verifier: ______) Date of Verification: Source:
5. Iowa Controlled Substances Verified (Initials of Verifier: ______)
6. Government Issued Picture ID Verified (Initials of Verifier: ______)
7. CPR/BLS Training Verified (Initials of Verifier: ______)
8. Delineation of Scope of Practice and Clinical Privileges: (Initials: ______) (Date: ______) ______
9. Evaluation of Clinical Competency and Proficiency: (Initials: ______) (Date: ______) ______
10. Verification of Fitness from Previous Employer: Date Received: ______
Employer Name / Address:
Comments: ______
11. Credentials presented to Community Board: (Initials of Presenter: ______) Date Presented:
12. Last Physical Reviewed: (Initials of Reviewer: ______) Date Reviewed: Date of Last Physical: Results:
13. Last PPD Verified: (Initials of Verifier: _____) Date of Verification: Date of Last PPD: Results:
14. National Practitioner Data Bank (NPDB) Query Completed:
(Initials of Person Completing Query: ______) Date of Query: ______
Notable Results:
15. Questions Presented Directly to Clinician: Do you currently have any medical or psychiatric condition that would affect your ability to exercise the clinical privileges requested, or that would require an accommodation in order for you to exercise those privileges safely and competently?
YES NO (Clinician Initials: ______) (Date: ______)
If “Yes”, please describe: ______
Have you used, or do you currently use, any illegal substances?
YES NO (Clinician Initials: ______) (Date: ______) Do you have any chemical or substance dependencies that could adversely affect your ability to exercise the requested privileges?
YES NO (Clinician Initials: ______) (Date: ______)
Are you currently under investigation by any state licensing board?
« YES NO (Clinician Initials: ______) (Date: ______)
If “Yes”, please describe the circumstances: ______
Are you subject to any pending malpractice, discrimination, or professional liability lawsuit or proceeding?
YES NO (Clinician Initials: ______) (Date: ______)
If “Yes”, please describe the circumstances: ______
Have any of your clinical privileges (outpatient or inpatient) ever been revoked, limited, suspended, withheld, voluntarily surrendered for cause, or been made subject to any special provisions?
YES NO (Clinician Initials: ______) (Date: ______)
If “Yes”, please describe the circumstances: ______
APPOINTMENT
The credentials of ______(name of clinician) are hereby accepted, and appointment is hereby made by the Community Board to the ______(behavioral health/medical/dental) staff of ______. Scope of practice and specific clinical privileges are as noted above (item #8).
______
Medical Director (Signature / Date)
______
CEO (Signature / Date)
______
Community Board President (Signature / Date)
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