4.f Assessor Request
Date: October 10, 2012
Re: Assessment Booking
The following physician has been randomly selected for assessment:
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
Yes, I will conduct this assessment but prefer to schedule at my convenience.
No, I am unable/unwilling to conduct this assessment because