Non-Physician Surgical First Assist Proctoring Form
Name of Non-Physician Surgical First Assist : _____________________________________________________ Name of Supervising Physician : ____________________________________________________________
Professionalism
� Is respectful of all members of the healthcare team . � Demonstrates ethically sound practices . � Is sensitive to cultural , age , gender , and disability issues .
No Concerns
Concerns / explanation : ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________
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ASSESSMENT : Performing within desired expectations Continue FPPE / proctoring Concern : The possibility of risk to patient safety exists
_____________________________________________________ Supervising Physician ’ s Signature
____________________________ Date
Review Form Revision : 11 / 20 / 2019 MM Page 5 of 5