Remity Staffing – Doctors Reference Form Remity Staffing - Reference Form (Doctors) Reference Form (Doctors) Date* Full Name of Candidate* GMC Number* Position Aplied for* Employed As Speciality* Grade From* To* NHS Trust* Nature of Relationship with Applicant* The above named doctor is presently working for you and as part of our recruitment process we would be greatful if you could complete the below tick box giving us a brief evaluation of their suitability for the post by completing the enclosed reference form. Your opinion of character, abilities, health and any other comments that you think are relevant would be most helpful. Please be advised that under the Data Protection Act, employees are allowed access to any information held on their personal files where any reference received would be located Investigation and Diagnosis Very GoodGoodAveragePoor Organisational Skills Very GoodGoodAveragePoor Judgement & patient management Very GoodGoodAveragePoor Practicle Skill Very GoodGoodAveragePoor Knowledge - Please tick appropriate box Basic Science Very GoodGoodAveragePoor Clinical Very GoodGoodAveragePoor Attitudes - Please tick appropriate box Reliability Very GoodGoodAveragePoor Time keeping Very GoodGoodAveragePoor Relationships - Please tick appropriate box Colleagues Very GoodGoodAveragePoor Patients Very GoodGoodAveragePoor Personal Qualities - Please tick appropriate box Appearance Very GoodGoodAveragePoor Integrity Very GoodGoodAveragePoor Manners Very GoodGoodAveragePoor Any other relevant Information* Has this person ever been the subject of disciplinary action or professional, Misconduct proceedings? please enter Yes or No (if yes please provide details)* Would you re-employee this person? (if No please provide details)* Referee's Details Name* Job Title* Organisation* Contact Number* Email* Signature* DrawType