Referee Instructions for Completion of Reference Forms

The referee physician should have had a close professional relationship with the applicant and should be in a position to
comment appropriately on the applicant’s clinical skills, abilities and character.
1. Complete all sections of the form below the signature of the applicant giving you consent to release to the College
confidential information with regard to the applicant.
2. Please return the completed form directly to the College by mail or by email using the contact information below.
Reference forms submitted via fax will not be accepted. Please also sign (or initial) the flap of the envelope after
sealing it.
Mail Jessie Janjua Email [email protected]
Registration Department
College of Physicians and Surgeons of BC
300–669 Howe Street
Vancouver BC V6C 0B4

3. Do not give the reference to the applicant to submit. Reference forms must be submitted directly to the College by
the referee. Submissions received from an email address that does not match the one provided on page 5 of the
reference form will not be accepted.
4. All references must be from physicians.
5. At least one reference must be from a program director, medical director, chief of staff or physician who was in a
supervisory role to the applicant for at least two (2) years.
6. At least one reference must be from a physician who has worked with the applicant in the past year.
7. A photo of the applicant is required to be submitted to the College with this reference form.
Note: It is essential that all of the above instructions be complied with to avoid delay in processing the application.

Yours truly,

Patrick Rowe, MD, CCFP (EM), FCFP

Registrar and CEO
Reference Form
APPLICANT INFORMATION

Surname: Oyeleke

Given name: Oyeronke

Click here to
City and province: Ilorin, Kwara State attach passport-
style photograph
Country: Nigeria taken recently or
attach photo
Discipline/specialty: Family Medicine separately

I authorize the referee to disclose to the College of Physicians and Surgeons of British
Columbia information otherwise confidential and I waive any right of disclosure of the same
to me and agree that communication between the College and the referee shall be privileged.

Signature:

ABOUT THIS FORM

The person named above has applied for registration with the College of Physicians and Surgeons of British Columbia. The
information you provide should be based on the applicant’s demonstrated performance compared to that reasonably
expected of a physician with similar levels of training and experience as the applicant.
The content of this form is confidential, for use by the College as part of the information submitted in support of the
candidate’s application, and will not be shared with the candidate or any other parties.

REFEREE ASSOCIATION WITH APPLICANT

1. Are you related to the applicant? ● Yes No

If yes, in what manner?

2. Do you know the applicant well enough to provide this reference? Yes ● No

If no, please contact the College before completing this form.

3. Please indicate which one of the following best describes your role when you knew this applicant and provide the
required information:

Postgraduate training programme director

Institution:

City and country:

Dates applicant was in your programme: From to

MM/YYYY MM/YYYY

Additional roles continued on next page

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Reference Form College of Physicians and Surgeons of British Columbia

Postgraduate training supervisor or preceptor

Institution:

City and country:

Dates applicant trained under you: From to

MM/YYYY MM/YYYY

Chief of service

Institution:

City and country:

Dates applicant known to you: From to

MM/YYYY MM/YYYY

Chief of staff or medical director

Institution:

City and country:

Dates applicant known to you: From to

MM/YYYY MM/YYYY

● Clinical colleague
Indicate which of the following apply to your working relationship with the applicant:
● A consultant to whom the applicant frequently referred patients
A colleague in a clinic where the applicant practised
● A colleague with whom the applicant shared on-call responsibility

City and country: Ilorin, Nigeria

Duration of working relationship with the applicant: From 01/2023 to 02/2025

MM/YYYY MM/YYYY

Other
Please describe your role when you knew this applicant:

City and country:

Duration of working relationship with the applicant: From to

MM/YYYY MM/YYYY

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Reference Form College of Physicians and Surgeons of British Columbia

APPLICANT INFORMATION
1. Clinical practice
Please provide your opinion of the applicant, within the range of services they provided and in comparison to their
peers, with respect to the following:
Among Bottom Average Top half Among Unable to
the worst half the best assess
Communicates effectively with patients and ● ● ● ● ●
families
Establishes respectful relationships with nursing ● ● ● ● ●
and other health-care professional staff
Establishes respectful relationships with physician ● ● ● ● ●
colleagues
Demonstrates appropriate clinical knowledge and ● ● ● ● ●
competence
Makes the correct diagnosis in a timely fashion ● ● ● ● ●

Demonstrates appropriate judgement ● ● ● ● ●

Performs technical procedures skillfully ● ● ● ● ●

Creates medical record and patient-related ● ● ● ● ●

documentation that is accurate, organized, and
completed in a timely manner
Please provide any comment or explanation regarding your answers:
She is very proficient in her duty as a medical practitioner and

2. Professional ethics
Do you consider the applicant to be:
Reliable Yes ● No ● Insufficient knowledge of applicant to answer

Ethical Yes ● No ● Insufficient knowledge of applicant to answer

Of good character Yes ● No ● Insufficient knowledge of applicant to answer

If no to any of the above, please provide an explanation:

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Reference Form College of Physicians and Surgeons of British Columbia

3. Professional conduct

a. To your knowledge, has the applicant ever engaged in:

Fraud or dishonesty ● Yes No

Unprofessional conduct ● Yes No

Excessive use of alcohol or other mood-altering substances ● Yes No

If yes to any of the above, please provide an explanation:

b. To your knowledge, has the applicant ever experienced any of the following:
Failure of any part of training ● Yes No

Discipline by hospital or training program ● Yes No

Loss of privileges or staff appointment ● Yes No

Discipline by licensing authority ● Yes No

If yes to any of the above, please provide an explanation:

4. Additional information

a. Would you refer your patients or family members to this applicant? Yes ● No

If no, please provide an explanation:

b. Please provide any other comments or information you feel important to include:

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Reference Form College of Physicians and Surgeons of British Columbia

REFEREE INFORMATION
Recommendations
I would recommend this applicant highly and without reservations.
● I would recommend this applicant as qualified and competent.
● I would recommend this applicant but with some reservation.
● I would not recommend this applicant.
Thank you for acting as a referee on behalf of the applicant. The information you provide is confidential, for the College
use as part of the information submitted in support of the candidate’s application, and will not be shared with the
applicant or any other parties.
Please note:
• This is a legal document.
• The applicant cannot be considered for appointment until this document is returned.
• The referee’s name, position, email address and phone number must be given.
• The referee’s signature is required in order for the reference to be considered complete.
If you have confidential information you would like to share with the College, please call 604-733-7758 or 1-800-461-3008
(toll-free in BC).
By signing below, I verify the information provided in this reference to be accurate to the best of my knowledge, and
the attached photo to be a true likeness of the applicant.

Surname: ODEDIJI Given name: TAWA

City and province: ILORIN, KWARA Country: NIGERIA

Email*: [email protected] Phone: 08064430297

Discipline/specialty: FAMILY MEDICINE

Signature: Date: 24/02/2025

*Reference forms must be submitted directly to the College. Please ensure that you send this reference from the email
address indicated here.

The information in this application form is collected under the authority of the Health Professions Act, RSBC 1996, c.183. The information provided will be
used for all purposes pertaining to registration with the College of Physicians and Surgeons of British Columbia. If you have any questions about the
collection and use of this information, please contact the College registration department at 300–669 Howe Street, Vancouver BC V6C 0B4, or call
604-733-7758 or 1-800-461-3008 (toll-free in BC).

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