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4.f Assessor Request

Email:

joanne.peat@usask.ca

Website:

www.pepsask.ca

Fax

To: Dr.

From:

Fax: *

Date: October 10, 2012

Re: Assessment Booking

Pages:One

Dear *:

The following physician has been randomly selected for assessment:

Name:

Dr. *

D.O.B.: *

Address: *

Graduated: *

Describes practice as: *.

Dr.* is now ready for assessment. Please indicate (by return fax) whether you would

be willing/able to conduct this practice assessment. Upon receipt of your confirmation,

correspondence will be sent to Dr. * advising that you will be the assessor. Scheduling

instructions and an assessment package will then be forwarded to you. If you would like

the PEP office to schedule this assessment, please fill in your dates of availability.

Yes, I will conduct this assessment and I am available to do so on the

following dates:

1.

2.

3.

Yes, I will conduct this assessment but prefer to schedule at my convenience.

No, I am unable/unwilling to conduct this assessment because

Thank you