PROFESSIONAL ASSOCIATE QUESTIONNAIRE
The Department of _____ places a high value on interpersonal skills and humanistic health care. In order to assess these qualities in our housestaff we
are asking you to complete this form for the resident physician named below. We are interested in your perception of their behavior during their last
rotation regarding relationships with other professionals, patients, and family members.
Resident Name ___________________________________________
Date____________________________

Please indicate the clinical setting where you have interacted with the resident:
Inpatient Unit

On average how many clinical observations did you have of the resident?
<4

Professional role:
Nurse
 Resident
 Technologist
 Medical Student
Outpatient Area
5-10
Other
10-20
>20
Other______________________________________
Unsatisfactory
Satisfactory
Communicates clearly; is willing to answer questions and provide explanations;
willing to listen to patients and families
1
2
3
4
5
6
7
8
9

Consistently demonstrates willingness to listen to nursing and allied health staff
1
2
3
4
5
6
7
8
9

Treats others with respect; does not demean or make others feel inferior; provides
equitable care to patients; uses respectful language when discussing patients; is
sensitive to cultural needs of patients
1
2
3
4
5
6
7
8
9

Consistently courteous and receptive to nursing and allied health staff;
acknowledges and respects roles of other health care professionals in patient care
1
2
3
4
5
6
7
8
9

3. Compassion
Is kind to patient and families; appreciates patients and families special needs and
accepts inconvenience when necessary to meet the needs of the patient;
consistently attentive to details of patient comfort
1
2
3
4
5
6
7
8
9

4. Reliability
Completes and fulfills responsibilities; responds promptly when on call or when
paged; assists and fills in for others when needed
1
2
3
4
5
6
7
8
9

5.Honesty/Integrity
Knows limits of ability and asks for help when appropriate; is honest and
trustworthy; does not falsify information; committed to ethical principles
1
2
3
4
5
6
7
8
9

6. Responsibility
Accepts responsibility (does not blame others or the system); committed to selfassessment; responds to feedback; committed to excellence and self-learning
1
2
3
4
5
6
7
8
9

7. Advocate
An advocate for patient needs, effectively accesses and coordinates medical system
resources to optimize patient care, seeks to find and correct system causes of
medical error
1
2
3
4
5
6
7
8
9

1. Communication
2. Respectfulness
Excellent
Unable to
assess
Comments:
Resident’s strengths____________________________________________________ How can the resident improve?_________________________________________
_____________________________________________________________________ _____________________________________________________ ___________
_____________________________________________________________________ ________________________________________________________________
_____________________________________________________________________ _____________________________________________________ ___________