Clinical Departing Form

Peer Evaluation Questionnaire

Completed form must be submitted with recredentialing/reaffirmation materials

For applicants who will have an appointment in the College of Medicine, e-mail pdf of signed consent to ellen-jenn@uiowa.edu and margery-pottorff@uiowa.edu

Summary of Your Rights under the Fair Credit Reporting Act (This must be given to the applicant when they are filling out the release).

Sent to Department of Human Services at the address listed on the form.

Sent to Department of Human Services at the address listed on the form.