Structured Reference Form for Specialty Training Post Applicants 2009
Name of Candidate: insert your name
Applying for Training Programme for Specialty training in: Obstetrics & Gynaecology – Insert Level
Please give a summary view of your professional opinion as to the suitability of this candidate for this post. If you wish to enlarge on any of your comments contained in the structured reference, please do so. You may use this proforma in the space below or, if you wish, attach a letter.
Please also complete the reference part of this form as comprehensively as possible. The aim is to receive your professional view of the applicant with reference to specific attributes in the person specification.
Signed ______
Name______
Date ______
Please complete the structured reference which follows overleaf.
I.Clinical Experience & Skills
A.Do you have any concerns about this applicant’s level of knowledge compared with other doctors at this level?
1.I have no concerns
2.I have some concerns which relate to ______
B.Do you have any concerns about the applicant’s overall clinical competence compared with other doctors at this level?
1.I have no concerns
2.I have some concerns which relate to ______
C.Do you have any concerns about the applicant’s awareness and insight into knowing when it is necessary to seek help/advice?
1.I have no concerns
2.I have some concerns which relate to ______
D.Do you have any concerns about the applicant’s ability to organise and prioritise clinical problems and personal work?
1.I have no concerns
2.I have some concerns which relate to ______
E.Do you have any concerns about the manual dexterity of the applicant?
1.I have no concerns
2.I have some concerns which relate to ______
II.Personal Skills
A.Communication skills (clarity, intelligibility, ability to build rapport, listen, persuade, negotiate)
Do you have any concerns about the applicant’s ability to demonstrate communication skills with colleagues and patients which promote teamwork and patient care?
1.I have no concerns
2.I have some concerns which relate to ______
B.Decisiveness/accountability (ability to take responsibility, make decisions, assert appropriate authority)
Do you have any concerns about the applicant’s ability to act decisively and take responsibility?
1.I have no concerns
2.I have some concerns which relate to ______
C.Interpersonal skills (ability to see patients as people, empathise, work co-operatively with others)
Do you have any concerns about the applicant’s ability to demonstrate interpersonal skills which promote good teamwork and which contribute to patient care?
1.I have no concerns
2.I have some concerns which relate to ______
D.Flexibility (ability to change and adapt, respond appropriately to rapidly changing circumstances)
Do you have any concerns about the applicant’s ability to demonstrate flexibility in day to day work?
1.I have no concerns
2.I have some concerns which relate to ______
E.Do you have any concerns about the applicant’s ability to deal with patients and colleagues in a non judgmental way regardless of their sexuality, ethnicity, disability, religious beliefs or financial status?
1.I have no concerns
2.I have some concerns which relate to ______
F.Resilience (ability to operate under pressure, cope with setbacks, self-aware)
Do you have any concerns about the applicant’s ability to demonstrate resilience in day to day work?
1.I have no concerns
2.I have some concerns which relate to ______
G.Thoroughness (is well-prepared, shows self-discipline and commitment)
Do you have any concerns about the applicant’s ability to demonstrate thoroughness in the approach to work?
1.I have no concerns
2.I have some concerns which relate to ______
H.Drive/enthusiasm (is a self-starter, motivated, shows curiosity)
Do you have any concerns about the applicant’s commitment, enthusiasm and drive for the specialty?
1.I have no concerns
2.I have some concerns which relate to ______
I.Probity (displays honesty, integrity, aware of ethical dilemmas)
Do you have any concerns about the applicant’s probity in the approach to patient care and in dealing with colleagues?
1.I have no concerns
2.I have some concerns which relate to ______
Please note – a copy of this reference will be made available, on request, to the candidate.
Signed ______Date ______
Name ______
Position ______
Hospital/ Trust ______
Thank you for taking the time to complete this reference. Please return to the candidate who will bring this with them to interview.
Common/Recruitment2008/Recruitment General Folder/Structured Reference Form