Rockfield Medical Campus, Balally, Dundrum, Dublin 16 Tel: 01 299 3550 Fax: 01 299 3551 E-mail: info@locumotion.com :www.locumotion.

com

REFEREE ASSESSMENT FORM

Applicant Name: _______________________ Name of Referee: _______________________

Hospital: ______________________________ Position: __________________________

Details for Referee Please complete the details below, rating the applicant according to the criteria by ticking the appropriate box, indicating if the applicants ability was as expected at their particular level of training.
Performance Requires Requires Performance Performance consistent Performance Substantial Further better than Just Adequate with level exceptional Assistance Development expected of experience

Clinical Skills
Medical Knowledge Procedural Skills Diagnostic Skills Clinical Judgement

Interpersonal Skills
Communication Skills Ability to work as a team member Communication with the friends & families of patients Reliability & dependability

Organisation
Application to work Organisation of work Medical record keeping

In what position did this person work for you: ____________________ For how long: _____________ Would you be prepared to have the applicant work for you again: __________ Further Comments: ________________________________________________________________ ___________________________________________________________________________________ Signature:______________________________ Date:______________________________________