EMPLOYMENT REFERENCE REQUEST

PRIVATE & CONFIDENTIAL

SECTION ONE - General Information

Name of Applicant: Medical Council Number (UK or Ireland):

This person worked under my supervision Yes No

(tick Yes/No as appropriate)

This person worked with me as a colleague Yes No

(tick Yes/No as appropriate)

From: To:

Clinical Site: Country:

Specialty:
Grade (e.g. SHO, Registrar, Consultant ):

Are you in any way related to the applicant Yes No

(tick Yes/No as appropriate)

What is your Relationship to the applicant:

SECTION TWO- Clinical Skills / Patient Safety & Quality of Patient Care

Excellent Good Fair Poor

Diligence in History taking & Record Keeping

Physical Examination
Diagnostic Investigations
Diagnostic Skills
Clinical Judgement
Patient contact
Ability to work alone
Operative / Clinical Skills
Application of work
Relating to Patients
SECTION THREE- Professional Attitude & Development

Excellent Good Fair Poor

Professionalism
Knowledge seeking / exams / CPD activities
Teaching Activities
Clinical Audit
Presentations
Learning / Seeking Guidance
Relating to Seniors (Consultants, Head of Department etc)
Application of work
Relating to Colleagues

SECTION FOUR- Personal Skills & Attributes

Excellent Good Fair Poor

Communication Skills / Interpersonal Skills

Teamwork
Leadership
Self-Awareness & Insight
Commitment & Motivation
Disposition & Appearance
Stress Management & Workload
Reliability
Time Management

SECTION FIVE - Additional Questions

Did this doctor performed well in this post?

Very well Acceptable Not Acceptable

Would you be happy to work again with this doctor?

Yes No
In your judgement is this applicant capable of independent clinical practice at their current grade in this discipline?

Yes No

To your knowledge has this applicant ever been the subject of a complaints process/ investigation relating to a
patient incident? If yes, please provide more details under the comment section.

Yes No

Do you think this doctor is suitable for a career in their chosen specialty?

Yes Unsure No

If you have any further comments/concerns regarding the candidate that Workplace Doctors not been covered
above, please use the space below or attach further correspondence.

We are Greatful & Thankful for your assistance today

Signed: Your Hospital / Company Stamp:

Print Name:

Date:

Job Title:

Name of Hospital / Company:

Please provide your daytime contact details in case we need to discuss any points further.

Telephone: Email:

PLEASE RETURN THE COMPLETED FORM TO WORKPACE DOCTORS

EMAIL: info@workplacedoctors.co.uk