Professional Qualifications Medical/Peer Reviewers

Instructions for completing DHA Form 780

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Section 1 – enter the Physician/Reviewer’s full name
Section 2 – enter the Physician/Reviewer’s year of birth.
Section 3 – enter the Physician/Reviewer’s complete address.
Section 4a. – enter the state in which the Physician/Reviewer is licensed.
Section 4b. – enter the year the Physician/Reviewer obtained his/her degree.
Section 4c. – enter name of school where Physician/Reviewer obtained his/her degree.
Section 4d. – enter the year Physician/Reviewer obtained his/her medical license.
Section 4e. – List all American Specialty Board affiliations for this Physician/Reviewer.
Section 4f. – List all area(s) of specialty for the Physician/Reviewer.
Section 4g. – List Physician/Reviewer’s type of practice (i.e. Family Practice).
Section 4h. – List all National Scientific Medical Society affiliations for the
Physician/Reviewer.
Section 5a . – List the state in which Physician/Reviewer has professional
appointment(s).
Section 5b. – List the name of the school(s) at which Physician/Reviewer has a
professional appointment.
Section 5c. – List Physician/Reviewer’s title and current status at the school listed in
section 5b.
Section 5d. – List any other additional professional appointments and pertinent
information about the Physician/Reviewer that supports his/her qualifications as an
expert in their respective field.
Section 6a. – Cite the name of the directory in which the Physician/Reviewer is listed.
Section 6b. – Provide the publication year.
Section 6c. – Provide the edition of the publication in which the Physician/Reviewer is
listed.
Section 6d. – Cite the page number of the Physician/Reviewer’s listing.
Section 6e. – List any other sources of Professional Listings for this Physician/Reviewer.
Include the year, edition/volume and page number.