Medical Employment Reference Form
Use this form to provide a professional reference for a candidate applying for a medical role.
Referee and Candidate Details
Referee full name
*
First Name
Middle Name
Last Name
Referee job title / role
*
Organization or facility name
*
Work email
*
example@example.com
Work phone
*
Please enter a valid phone number.
Format: (000) 000-0000.
Relationship to candidate
*
Direct supervisor
Colleague
Department lead
Educator / preceptor
Other
Candidate full name
*
First Name
Middle Name
Last Name
Position applied for
*
Department / unit (if applicable)
Employment Reference Evaluation
Dates Worked Together
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Candidate's Role During That Period
*
Overall Performance Rating
*
1
2
3
4
5
Clinical Competence Rating
*
1
2
3
4
5
Communication Skills Rating
*
1
2
3
4
5
Professionalism Rating
*
1
2
3
4
5
Teamwork Rating
*
1
2
3
4
5
Reliability and Punctuality Rating
*
1
2
3
4
5
Patient Care Attitude Rating
*
1
2
3
4
5
Would You Recommend the Candidate for a Medical Position?
*
Strongly recommend
Recommend
Recommend with reservations
Do not recommend
Detailed Feedback and Confirmation
Comments on strengths
Areas for improvement
Relevant workplace observations
Additional comments
Referee confirmation signature
*
Submit Reference
Submit Reference
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