Special Skills and Qualifications
Summarize any special skills and qualifications that you have aquired from employment or other experience.
I understand that the Program is responsible for the evaluation of my professional
competence and qualifications, and has the obligation to inquire into my professional
training, experience, professional conduct and judgment, and to make appropriate
recommendations to the governing body of this Program.
By filing an application for employment and privileges, and in connection with this
application, I agree to be bound by the policies of the Program, and the bylaws, rules and
regulations of the professional staff, as adopted by the board and the applicable laws of the
State of California.
I agree that it is my duty and ethical responsibility as an individual and as an employee of
this Program to cooperate with and assist the Program in evaluating not only my
professional qualifications but also those of my colleagues. I agree to appear before the
Executive Director, Clinical Services Director and Committees for interview or inquiry at
reasonable times and places. I consent to the communication of information and
documents between this professional staff and other professional staffs, schools, training
programs, societies, professional associations, professional liability insurance companies,
national practitioner data bank, and licensing authorities in the jurisdiction in which I have
trained, resided, or practiced, for the evaluation of my professional training, experience,
character, conduct and judgment.
I release from any liability all individuals and organizations who provide information in good
faith and without malice concerning my competence, ethical conduct, character and other
qualifications for staff appointment and clinical privileges, including otherwise privileged
Evaluation and inquires into my professional competence and qualifications shall be
accomplished in a professional manner. I hereby affirm that the information furnished by me
is true to the best of my knowledge and is furnished in good faith. I understand that willful
and substantial omissions or misrepresentations may result in denial, modification, or
revocation of my privileges or termination of employment.