Joint reference form

For The Schulich School of Medicine & Dentistry, London Health Sciences Centre,  and St. Joseph’s Health Care London.

Instructions to the applicant:

  • You are required to obtain three confidential references with your application for your academic appointment with Schulich School of Medicine & Dentistry and hospital privileges.

  • Your referees should be someone who has worked with you within the last two years and must include at least one of the following:  a Supervisor, Program Director, Department Chief, Chief of Staff or CEO.

Instructions to the referee:

  • Your personal knowledge of this  applicant is important in judging suitability for appointment and privileges.  Any concerns that you identify below should be explained.

  • This is a confidential reference and will not be shared with the applicant at any time.

  • Reference letters will not be accepted in lieu of this reference form.

  • Call 519 667-6844 with any questions

Applicant details
Professional relationship to applicant
Are you or have you supervised the candidate?
Is the applicant related to you?
Ability to work with and relate to staff and leaders in a collegial and professional manner:
Ability to communicate and relate appropriately with patients and their families:
Clinical knowledge and competence:
Satisfaction of “on-call” responsibilities:
Completion of clinical record documentation:
General compliance with Public Hospitals Act, Credentialed Professional Staff By-Laws, and other relevant legislature:
Patient management (ie. monitoring of patients):
Utilization of hospital resources:
Willingness to participate in clinical, teaching and/or research responsibilities and obligations:
Ethical judgement:
Professional conduct
Does the applicant meet the requirements for continuing medical education? (attends conferences, grand rounds, journal clubs)?
Are you aware of any situation where the applicant has interacted inappropriately with patients or their families?
Summary recommendations
Recommendation
Declaration
By checking this box, I confirm that the information submitted within this reference is correct to the best of my knowledge and belief:
Are you aware of any situation where the applicant has been the subject of any professional misconduct proceeding?
Are you aware of any situation where the applicant has engaged in professional practice patterns that would endanger patient safety or welfare?
Are you aware of any situation where the applicant’s academic appointment has been denied, suspended, revoked, modified or voluntarily surrendered?
Does the applicant have any health related conditions or practices that would impact his/her ability to practice medicine, dentistry, midwifery or nursing?