Reference Form - Doctors Application Reference * Date * MM DD YYYY Referee Name * First Name Last Name Capacity in which you know the applicant * Clinical Skills Delivery of Care * Very Good Good Satisfactory Less than Satisfactory N/A Ability to carry out clinical skills * Very Good Good Satisfactory Less than Satisfactory N/A Drug Administration * Very Good Good Satisfactory Less than Satisfactory N/A Assess patient needs and prioritise care * Very Good Good Satisfactory Less than Satisfactory N/A Able to hand over care suitably * Very Good Good Satisfactory Less than Satisfactory N/A Knowledge Robust understanding of diseases/conditions * Very Good Good Satisfactory Less than Satisfactory N/A Demonstrate knowledge of clinical procedures * Very Good Good Satisfactory Less than Satisfactory N/A Able to recognise own limitations * Very Good Good Satisfactory Less than Satisfactory N/A Attitude Reliability Very Good Good Satisfactory Less than Satisfactory N/A Timekeeping * Very Good Good Satisfactory Less than Satisfactory N/A Conflict Management * Very Good Good Satisfactory Less than Satisfactory N/A Communication/Interpersonal Skills Language Skills * Very Good Good Satisfactory Less than Satisfactory N/A Willingness to listen to patients and families * Very Good Good Satisfactory Less than Satisfactory N/A Willingness to listen to all clinical and non-clinical colleagues * Very Good Good Satisfactory Less than Satisfactory N/A Explains information to patients and families using clear, understandable terms * Very Good Good Satisfactory Less than Satisfactory N/A Keeps patients, families and colleagues informed of changes in the care plan * Very Good Good Satisfactory Less than Satisfactory N/A Cooperates when approached by colleagues with questions * Very Good Good Satisfactory Less than Satisfactory N/A Relationships and Maintaining Trust Building relationships with patients and relatives * Very Good Good Satisfactory Less than Satisfactory N/A Ability to work well in a team * Very Good Good Satisfactory Less than Satisfactory N/A Appearance * Very Good Good Satisfactory Less than Satisfactory N/A Professionalism and conduct * Very Good Good Satisfactory Less than Satisfactory N/A Would you happy to re-employ this applicant? * Yes No Please provide further comment below if required. Referee Details Name * First Name Last Name NHS Email Address * Position * GMC Number Date * MM DD YYYY Organisation Details Organisation Name * Address Thank you! You will shortly receive a verification email to your NHS email - please kindly reply promptly to verify this reference.
