Letter Headed Paper Templates - DOC

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					Insert name and address of referee
Insert name and address of referee
Insert name and address of referee
Insert name and address of referee




Date
Dear Referee
Re : {insert name of applicant and post applied for}
This applicant has applied for an appointment to an academic training programme recruited to by London
Deanery.
The deanery has developed an appointment process which seeks clearly to identify the characteristics
required for training with an understanding that many of these individuals will become NHS consultants in the
future. This is reflected in the person specification which describes in detail the features of each of the criteria
being assessed and the point in the application process when evaluation takes place.
This reference form has been designed to ask you for specific information about the applicant which can only
be obtained by asking your views. Some of the characteristics are difficult to assess, but if you do have any
concerns about the candidate’s abilities, we would be grateful if you would describe these. We would also
appreciate your professional view of the suitability of the candidate for this programme. Please note that
according to “A Guide to Specialist Training” (February 1998), “completed reference forms should be made
available to all candidates on request”.

Please print the form on letter headed paper or stamp the form using the hospital stamp and
sign and date the bottom of the form.

Please return the completed reference in a sealed envelope to the candidate as this will be collected at
interview.
If you have any questions, please contact our recruitment enquiries team -
recruitmentenquiries@londondeanery.ac.uk


Thank you very much for participating in this process.


Yours sincerely


Medical Workforce Recruitment Team - London Deanery
Structured Reference Form for applicants applying to Academic Training programmes


Name of Candidate:
Applying for training programme in:
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.




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Please circle the relevant box. If you do have any concerns about the applicant, please complete the box
overleaf, giving the reason for your concerns.

1.       Clinical Experience & Skills
Do you have any concerns about this applicant’s level of knowledge compared with              YES   NO
other doctors at this level?

Do you have any concerns about the applicant’s overall clinical competence compared YES             NO
with other doctors at this level?

Do you have any concerns about the applicant’s awareness and insight into knowing             YES   NO
when it is necessary to seek help/advice?

Do you have any concerns about the applicant’s ability to organise and prioritise clinical YES      NO
problems and personal work?

Do you have any concerns about the manual dexterity of the applicant?                         YES   NO

2.       Personal Skills
Communication skills (clarity, intelligibility, ability to build rapport, listen, persuade,   YES   NO
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?

Decisiveness/accountability (ability to take responsibility, make decisions, assert           YES   NO
appropriate authority)
Do you have any concerns about the applicant’s ability to act decisively and take
responsibility?

Interpersonal skills (ability to see patients as people, empathise, work co-operatively       YES   NO
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?

Flexibility (ability to change and adapt, respond appropriately to rapidly changing           YES   NO
circumstances)
Do you have any concerns about the applicant’s ability to demonstrate flexibility in day
to day work?

Do you have any concerns about the applicant’s ability to deal with patients and              YES   NO
colleagues in a non judgmental way regardless of their sexuality, ethnicity, disability,
religious beliefs or financial status?

Resilience (ability to operate under pressure, cope with setbacks, self-aware)                YES   NO
Do you have any concerns about the applicant’s ability to demonstrate resilience in day
to day work?
Thoroughness (is well-prepared, shows self-discipline and commitment)                     YES         NO
Do you have any concerns about the applicant’s ability to demonstrate thoroughness in
the approach to work?

Drive/enthusiasm (is a self-starter, motivated, shows curiosity)                          YES         NO
Do you have any concerns about the applicant’s commitment, enthusiasm and drive for
the specialty?

Probity (displays honesty, integrity, aware of ethical dilemmas)                          YES         NO
Do you have any concerns about the applicant’s probity in the approach to patient care
and in dealing with colleagues?



3. Academic

Do you have any concerns about the applicant’s commitment to an academic career?          YES         NO

Do you have any concerns about the applicant’s academic competences                       YES         NO

Do you have any concerns about the applicant’s potential to develop a successful          YES         NO
academic career?

Please comment on any other relevant aspect or contribution and role played by the candidate in academic
output, grant applications, personal fellowship / funding, nature and quality of any academic output and
qualifications etc

Comments / evidence




If you have answered yes (indicating a concern) for any of the attributes listed above, please give
your reasons for your concerns in the box below




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Please note – a copy of this reference will be made available, on request, to the candidate.


Signed ___________________________________________ Date __________________
Name ____________________________________________
Position __________________________________________
Hospital/ Trust _____________________________________
The candidate worked with me from {insert date} to {insert date}


Thank you for taking the time to complete this reference. Please put it in a sealed envelope and return it to the
candidate, so that he / she can bring it to the interview.


If you have any questions, please contact our recruitment enquiries team -
recruitmentenquiries@londondeanery.ac.uk




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