University of Ottawa Enhanced Skills for Family Practice Residency Program Referee Assessment of Applicant

Thankyouforservingas areference.Inchoosingresidents for this Program, the Selection Committee placesa good dealofemphasisontheinformationprovidedby medical faculty who have observed theapplicant in the clinicalsetting.Wewouldthereforerequestyourcandidcommentsincompletingthisquestionnaire.The program asksyoutopleasecompletethisform in additiontoa formal personalized letterof reference.Your early reply is appreciated, as the candidate's application will not beevaluatedwithout yourappraisal.Occasionally, follow up is requiredforclarification.

PLEASE SUBMIT to Julia Testa by email or by fax (613-562-6336)

Maywecallyou to discuss this application if needed?☐Yes☐No

NAME OF APPLICANT:

1.In what setting have you observed the applicant?

A.Clinical Observation (specify):

B.AcademicAdvising:

C.Socially:

D.Other (pleasespecify)

2.Howwelldoyouknowtheapplicant?

☐VeryWell☐FairlyWell☐Slightly

Howlonghaveyouknowntheapplicant?

3.Toyourknowledge,hasthereever beenanydisciplinary/legalaction or psycho/socialbehaviourinvolvingthis applicant which might indicate unsuitability for .

(ESFP Program of Interest, e.g., Sport and Exercise Medicine, Family Practice Anesthesia, etc.)

☐Yes☐NoIfyes,pleaseincludedetailsinreferenceletter.

4.Pleaseselect the statement whichbest applies tothis applicant:

☐Performingfar belowlevel expectedofanFMresident.

☐Performingbelowlevel expected ofanFMresident(butshouldbeconsideredforanR3position).

☐Performingat level expected of an FM resident.

☐In theupper25%ofFMresidents(excellentresident,wellaboveexpectedperformance).

☐In theupper5%ofFMresidents(truly exceptional).

Please indicatewitha check (√) foreach factorbelowyouropinion of this applicant’sposition on that factor relative to other FamilyMedicine residents you have known.

Unable to judge / Unacceptable / Belowaverage / Average / Aboveaverage / Excellent
1.Medical judgment: gathers anduses data efficiently and effectively; defines problemsandisarationalproblem-solver;ordersinvestigations
inadeliberateandplannedmanner;abletodifferentiatebetweentheideal
and reality; recognizesownlimitationandseekshelpappropriately / ☐ / ☐ / ☐ / ☐ / ☐ / ☐ /
2.Organizational skills:makesgooduseoftimeandresources / ☐ / ☐ / ☐ / ☐ / ☐ / ☐ /
3.Interpersonal skills:rapport, co-operation, attitudes towards supervision, sense of humour, empathy,sensitivitytotheneedsofothers / ☐ / ☐ / ☐ / ☐ / ☐ / ☐ /
4.Insight:self-assessesaccurately,recognizeslimitations,planslearning, resourcefulness, originality, skillful management of available resources, ability to function independently, self-confident, assuredness / ☐ / ☐ / ☐ / ☐ / ☐ / ☐ /
5.Motivation: seeks out opportunities andassumes responsibility;shows spontaneousinitiative,readytoworkhard,andhasadesiretoachieve / ☐ / ☐ / ☐ / ☐ / ☐ / ☐ /
6.Reliability:dependability,senseofresponsibility,promptness, conscientiousness, integrity / ☐ / ☐ / ☐ / ☐ / ☐ / ☐ /
7.Maturity: personaldevelopment, ability to cope with life situations / ☐ / ☐ / ☐ / ☐ / ☐ / ☐ /

Pleasecheck one of the following:

☐I wouldnotrecommendthisresidentforPGY-3 training

☐I wouldrecommendthisresident withsomereservation

☐Iwouldrecommendthisresident

☐I wouldrecommendthisresidentwithoutreservation

Name (Please print)

Title

Signature

Date

Telephone

Thank you for including this form with your letter of reference for this candidate.

Please return to Julia Testa by email or by fax (613-562-6336).

Adapted from the Family Medicine-Emergency Medicine (EM) Residency Program Referee Assessment of Applicant-2012