Credentials summary and Evaluation From (Health Care Professional)
The applicant Name :………………………………………………………………………………
Employee Number:…………………………………………………………………………………
The job Title :…………………………………………………………………………………………………
CREDENTIALS
1. Educational degree : Specialty:………………………….
Bachelor
Master
Fellowship
PHD Others:………………………………………………………………………
Certificates verified: Yes NO
2. Experience:
A……………………………………………………………………………………………………………………
B……………………………………………………………………………………………………………………
C……………………………………………………………………………………………………………………
Experience certificates verified : yes No N\A
3. License :
……………………………………………………………………………………………………………………….
License valid and verified : yes No
4. Training:
…………………………………………………………………………………………………………………..
5. Life Support Certificates:
BLS ( ) ACLS ( ) PALS ( ) NRP ( ) ATLS( ) ALSO ( ) OTHERS ( )
EVALUATION
The applicant meeting the requirement of job position:(…………………………………………)
Comment:
……………………………………………………………………………………………………………………
……………………………………………………………………………………………………………………
APPROVAL
Job Title Name Signature Date
Head of Department
Human Resources Auditor
Medical director (Head of CPC
committee)
