One of your peers has applied for membership to the Outpatient Endovascular and Interventional Society.

Please take a few moments to complete this short survey to provide your professional insights to our Membership Committee.

Your responses will be kept confidential.

Applicant's Name:
Your Name:
Your Email:
Your Credentials:
Your Specialty:
 
How long have you known the applicant?
0-1 year
2-5 years
6-10 years
more than 10 years
 
Does the applicant currently perform outpatient angiographic procedures in an office-based angiography suite?
Yes
No
I don't know
 
Have you had the opportunity to observe the applicant's work?
Yes
No
 
Please rate the applicant in the following areas:
Strongly
Disagree
DisagreeAgreeStrongly
Agree
Knowledgeable practitioner
Skilled practitioner
Practitioner of high moral and ethical standards
 
Please elaborate on your response that you "strongly disagree" or "disagree" that the applicant is a knowledgeable practitioner:
 
Please elaborate on your response that you "strongly disagree" or "disagree" that the applicant is a skilled practitioner:
 
Please elaborate on your response that you "strongly disagree" or "disagree" that the applicant is a practitioner of high moral and ethical standards:
 
Would you hire the applicant to work for you in practice?
Yes
No
 
Please elaborate on your response that you would not consider hiring this applicant to work in your practice:
 
Do you recommend the applicant for admission into the Outpatient Endovascular and Interventional Society?
Do not recommend
Recommend with reservation
Recommend
Highly Recommend
 
Please elaborate on your response that you do not recommend or recommend with reservation:
 
Would you be willing to speak with a committee member to further discuss your indication that the candidate not be accepted as an OEIS member or that you recommend with reservation?
Yes
No
 
Please provide us with your best contact phone number:
What is the best time to contact you?
 
Would you like to add any comments?
Yes
No
Please comment below:
 
Today's Date:
 
Please re-type your name below. This entry will serve as your electronic signature on your peer survey for the applicant.