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Form 3C.4Montefiore aesculapian core & Montefiore Associate IPAs Confidential - lord Reference Evaluation TO: ________________________________________DATE:_____ September 8, 2009______ applicator: ____Gabriel J. Kaufman, MD__________ DEPARTMENT: ______________________ The above listed doc or allied health provider is soon applying for clinical privileges at our facility and/or for membership in the Montefiore Associated IPAs. dishonor complete the form and excrete it directly blanket to us via fax or escape at: Montefiore Medical marrow/CMO 200 Corporate Drive, Yonkers, NY 10701 telephony:(914) 377-4690 Fax:(914) 377-4791 This military range should be based on demonstrated bring aboutance compared to that of what is much or less judge of a practitioner at his/her aim of training, experience and background. I. birth OF compose TO APPLICANT 1. Your title or note at the sentence of observance: ______Pediatric Resident_________________ 2. Dates of observation: _07_/_01_/_05 to _06_/_30_/_07__ II. APPLICANT’S PROFESSIONAL KNOWLEDGE, SKILLS AND ATTITUDE 1. ar there any clinical areas, procedures, or patient naughtiness levels, which you would be concerned about allowing the applier to manage/perform if she/he were in put on with you?

No X Yes ( If yes, enthral explain: _________________________________________________ ____________________________________________________________ ______________________ 2. Have you invariably observed or been certified of any physical, mental, health, drug, alcohol dependence or other problems which the applicant has that have or could potentially impair his/her ability to institutionalize medicine in a reasonably safe and skilful manner? No X Yes ( If yes, please explain: _________________________________________________ ____________________________________________________________...If you occupy to get a profuse essay, order it on our website: Ordercustompaper.com

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