● This referee report will be used for all positions the applicant has applied for during the

e Annual Junior Medical

Officer Recruitment campaign. However, a convenor may also seek further clarification from a referee on information
provided in the referee report or raised during the interview phase.
● If this referee report has been completed online or in writing you will be contacted by a Medical Administration

representative to verify the referee report was completed by you.

● Please complete the questions below. In providing your responses you may wish to consult with others that have

worked with the applicant and have direct knowledge of their skills, performance and competencies.
● By completing this referee report you are confirming that you are providing an honest, accurate and completed

response to each question.

● The information you provide may form part of any feedback to the applicant.

Basic Details

NAME OF APPLICANT:

Name of Referee:

Position Title and Organisation:

Email Address:

Contact Number:

Relationship to Applicant: *
Were you his/her supervisor?, if so when?: Please select *
Length of time you have known the applicant / dates you have worked with applicant:

*
A. How would you describe the applicant's skills/experience/competence (as appropriate) in the workplace in
relation to the question outlined the below?

Clinical Decision Making

a. How would you assess the applicant's ability to apply their clinical knowledge and concepts to clinical situations?

n Poor
j
k
l
m

j Satisfactory
k
l
m
n

j Good
k
l
m
n

j Excellent
k
l
m
n

j Not able to comment

k
l
m
n

Further comments (if any):

b. How would you assess the applicant's clinical judgement, skills and ability to perform appropriate clinical assessments?

j Poor
k
l
m
n

n Satisfactory
j
k
l
m

j Good
k
l
m
n

j Excellent
k
l
m
n

j Not able to comment

k
l
m
n

Further comments (if any):

Organisation and planning

c. How would you assess the applicant's willingness to participate in quality improvement activities that contribute to improving
patient care?

j Poor
k
l
m
n

j Satisfactory
k
l
m
n

j Good
k
l
m
n

n Excellent
j
k
l
m

j Not able to comment

k
l
m
n
Further comments (if any):
d. How would you assess the applicant's ability to manage their time and competing priorities?

n Poor
j
k
l
m

j Satisfactory
k
l
m
n

j Good
k
l
m
n

j Excellent
k
l
m
n

j Not able to comment

k
l
m
n
Further comments (if any):

Collaboration

e. How would you assess the applicant's ability to maintain positive relationships within the workplace?

j Poor
k
l
m
n

n Satisfactory
j
k
l
m

j Good
k
l
m
n

j Excellent
k
l
m
n

j Not able to comment

k
l
m
n

Further comments (if any):

f. How would you assess the applicant's ability to prevent, negotiate and resolve conflict between peers and other disciplines?

j Poor
k
l
m
n

j Satisfactory
k
l
m
n

j Good
k
l
m
n

n Excellent
j
k
l
m

j Not able to comment

k
l
m
n

Further comments (if any):

Learning
g. How would you assess the applicant's ability to accept feedback, learn from experience and modify their behaviour
appropriately?

n Poor
j
k
l
m

j Satisfactory
k
l
m
n

j Good
k
l
m
n

j Excellent
k
l
m
n

j Not able to comment

k
l
m
n

Further comments (if any):

h. How would you assess the applicant's willingness to take advantage of learning opportunities and their commitment to
ongoing education and training?

j Poor
k
l
m
n

n Satisfactory
j
k
l
m

j Good
k
l
m
n

j Excellent
k
l
m
n

j Not able to comment

k
l
m
n

Further comments (if any):

Professionalism

i. How would you assess the applicant's ability to act appropriately and respectfully toward colleagues and patients?

j Poor
k
l
m
n

j Satisfactory
k
l
m
n

j Good
k
l
m
n

n Excellent
j
k
l
m

j Not able to comment

k
l
m
n
Further comments (if any):

j. How would you assess the applicant's punctuality and attendance in the workplace?

j Poor
k
l
m
n
j Satisfactory
k
l
m
n

j Good
k
l
m
n

j Excellent
k
l
m
n

n Not able to comment

j
k
l
m
Further comments (if any):

Communication

k. How would you assess the applicant's ability to build a rapport and convey relevant information and explanations to patients
and their families?

n Poor
j
k
l
m

j Satisfactory
k
l
m
n

j Good
k
l
m
n

j Excellent
k
l
m
n

j Not able to comment

k
l
m
n

Further comments (if any):

l. How would you assess the applicant's ability to convey clear and timely written and verbal information to colleagues and
maintain adequate record documentation?

j Poor
k
l
m
n

j Satisfactory
k
l
m
n

n Good
j
k
l
m

j Excellent
k
l
m
n

j Not able to comment

k
l
m
n
Further comments (if any):

B. Would you re-employ the applicant if the opportunity arose? Why / Why not?
 *

C. Are you aware of any professional conduct or past performance issues that may be relevant and appropriate for
us to consider?

D. Is there anything else you think would be relevant for us to consider?