Reference Report: International Medical Graduates: Specialist Pathway

Reference Report

International Medical Graduates: Specialist Pathway
You may submit this form anonymously if you prefer. All information you provide will be treated in confidence.
Referee Name*
Applicant Name*
Email*
example@example.com
Telephone (please include country and area codes)*
1. For how long have you known the applicant on a professional basis?*
2. Please provide the date and description of your most recent professional contact with the applicant*
3. Are there any particular clinical areas in which you feel the applicant may require further training before commencing practice in Australia?*

YesNo
If yes, what are the areas in which you feel the applicant may require training?:
4. Have you been satisfied with the applicant's good standing in relation to their moral and ethical behaviour, and that their professional contact and relationships with patients and staff are of a high standard?*

YesNo
Comment:*
5. Are you aware of any adverse findings, restrictions of practice, and limitations in clinical competence about the applicant?*

YesNo
If yes, please comment
6. Do you believe the applicant is suited to practice dermatology independently in a general setting?*

YesNo
Comment*
7. Any other comments*
I certify that:*

All statements and information provided in this reference are true and accurateI have been professionally associated with the applicant in the past two years
Date*

DayMonthYear
Date
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