Reference Report: International Medical Graduates: Specialist Pathway

Reference Report

International Medical Graduates: Specialist Pathway
This form is to be completed by international medical graduates working in a short term training position approved by the Australasian College of Dermatologists.

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
Should be Empty: