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National Reference Form ORIEL

This two-page document is a structured reference form for a doctor applying to a specialty training programme. It requests factual information about the applicant's employment, attendance, disciplinary history, criminal record, and the referee's willingness to work with and recommend the applicant. The referee is asked to verify information and provide comments honestly and justifiably, including all relevant information related to the applicant's competence, performance, reliability, and conduct.

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Chengyuan Zhang
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921 views

National Reference Form ORIEL

This two-page document is a structured reference form for a doctor applying to a specialty training programme. It requests factual information about the applicant's employment, attendance, disciplinary history, criminal record, and the referee's willingness to work with and recommend the applicant. The referee is asked to verify information and provide comments honestly and justifiably, including all relevant information related to the applicant's competence, performance, reliability, and conduct.

Uploaded by

Chengyuan Zhang
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOC, PDF, TXT or read online on Scribd
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Page 1 of 2 :

USE FOR INTAKE: AUG 2016

Structured Reference Form


For applications to Specialty Training Programmes

The doctor to whom this reference refers has applied for a specialty training placement and has given your
name as a referee and we would be grateful if you could provide us with information required below. Please
note we can only accept references on this structured reference form. This professional reference should
verify factual information only; we do not require you to provide a personal testimonial or an assessment of
the candidate. Your responses may be discussed with the applicant named above and/or his/her trainer.
Your reference may also be made available to other departments within the NHS.

This reference form has been developed with the General Medical Council publication Good Medical
Practice in mind. Your attention is drawn to the following paragraph:

When providing references for colleagues, your comments must be honest and justifiable; you must
include all relevant information which has a bearing on the colleagues competence, performance,
reliability and conduct (GMC Good Medical Practice, Second Edition, July 1998 The duties of a doctor registered with the
General Medical Council, Item 11 References.)

Applicant Name:
Applicant GMC/GDC No Applicant Ref No
Post Applied For:

Please confirm the applicants employment details that are covered by this reference:

Date started: Date finished:

Position held by applicant: Level / grade:


(level and specialty)
Specialty:

Trust name /location:

Clinical Supervisor
Your relationship to applicant: Educational Supervisor
Other (please specify)

Was their attendance /timekeeping satisfactory?

YES NO If No, please give details

Was the applicant subject to any disciplinary procedure, formal or otherwise, during their time with you?

YES NO If Yes, please give details:


Page 2 of 2 :
USE FOR INTAKE: AUG 2016

Structured Reference Form


For applications to Specialty Training Programmes

The post applied for is exempt from the provision of section 4 (2) of the Rehabilitation of Offenders Act 1974 (exceptions
order 1975). Under this order are you aware of any criminal convictions or cautions which may affect the applicants suitability for the
post?*

YES NO If Yes, please give details:

*It is contrary to the Act for referees not to reveal any information they may have, concerning convictions which may otherwise be
considered spent in relation to this application which you consider relevant to the applicants suitability for employment

Would you be happy to work with this doctor again? YES NO


Are you able to recommend this applicant for the post they
YES NO
have applied for?
If you have any other comments regarding this applicant and his/her application for this post, please give details here:

SIGNATURE NAME (print in block capitals)

POSITION HELD CONTACT TELEPHONE NO.


Name of hospital or
E-MAIL ADDRESS
training practice
If NOT registered with the UK
GMC: Give name of your
Your UK GMC Number
registering body & Your
Registration Number:
If not registered with the UK GMC please attach photocopy evidence of
your professional status to this reference

Full Postal Address

DATE (dd/mm/yyyy)

It is essential that this form is stamped with an official hospital stamp. If no stamp is available, please attach a compliment slip signed by the
consultant providing the reference. Forms received without a stamp or a signed compliment slip will be returned.
Official hospital stamp (or training practice stamp)

Thank you for completing this reference.


This form should be handed back to the applicant in a sealed envelope.
If you have returned the completed form by e-mail, please ensure that a
paper copy is returned by post.

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