REFERENCE FORM
This evaluation should be based on demonstrated performance compared to that reasonably expected of a
physician with a similar level of training, experience and professional background as the applicant. Please
complete all parts of this form.
Full Name of Applicant ____________________________________________________________________________
CPSO File # (If Known) ___________________________
SECTION 1 Referee Information
Full Name of Referee ______________________________________________________________________________________
Primary Site of Practice _______________________________________________________________________________
Current Position / Title _______________________________________________________________________________
a) Is the applicant related to you? Yes No
b) Do you work in the same location as applicant? Yes No
c) In what capacity do you currently work with the applicant?
Program Director _____ Chief of Staff _____ Department/Division Head _____
Senior Colleague _____ Medical Director _____ Nurse _____
d) Are you presently in a position of formal authority over the applicant’s work? Yes No
If No, please explain _______________________________________________________________________
_______________________________________________________________________
e) How long have you worked with the applicant? From ________ /_______ To ________ /_______
f) Name of hospital/clinic/university where you presently work with the applicant
___________________________________________________________________________________________________
___________________________________________________________________________________________________
SECTION 2 Applicant Information
Description of Applicant’s Medical Activities
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REFERENCE FORM
In your experience working with the applicant, please rate the applicant in the following competencies with any
concerns related to the applicant noted in section H:
a) Medical Expert
Above Average Average Below Average Unknown
Basic scientific knowledge
Basic clinical knowledge
History and physical examination
Orders test appropriately
Interpretation and utilization of information
Clinical judgment and decision making
Technical skills required in the specialty
Overall performance
b) Communicator
Above Average Average Below Average Unknown
Interprofessional relationships with physicians
Communication with other allied health
f i l
Communication with patients
Communication with families
Written communication & documentation
c) Collaborator
Above Average Average Below Average Unknown
Asks for referrals appropriately to physicians
and non- physicians
Interacts and consults effectively with health
professionals by recognizing and
acknowledging their roles and expertise
Delegates effectively
d) Leader
Above Average Average Below Average Unknown
Understands and uses information technology
Uses health care resources cost-effectively
Organization of work and time management
e) Health Advocate
Above Average Average Below Average Unknown
Advocates for the patient
Advocates for the community
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REFERENCE FORM
f) Scholar
Above Average Below Average Unknown
Motivation to read and acquire knowledge
Critically appraises medical literature
Teaching skills
Completion of research/project
g) Professional
Above Average Below Average Unknown
Integrity and honesty
Sensitivity and respect for diversity
Responsibility and self-discipline
Communicates with patients with
compassion and empathy
Recognition of own limitations, seeking advice
when needed
Understands principles of ethics; applies to
clinical situations
Understands boundary issues/ethical limits
h) Strengths and Areas of Improvement
What are the applicant’s greatest strengths?
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
What areas of improvement and development have been identified for the applicant?
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
i) Other
Do you have any additional information with respect to this applicant which may be relevant to his/her
application for registration to practice medicine in Ontario?
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
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REFERENCE FORM
SECTION 3 Summary Recommendation
Recommend without Reservations
Recommend with Reservations
Do Not Recommend
If recommending with reservations or do not recommend, please explain:
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
Please email / call me to discuss this applicant Yes No
E-mail
Phone number ( )
Best time to call:
Full Name
Title
Signature
Date
Reference forms sent by the applicant are not acceptable. The referee must return the completed form
directly to the College. Please email a scanned copy to [email protected] or mail the original in an
official or stamped envelope to:
The College of Physicians and Surgeons of Ontario
Registration & Membership Services
80 College Street Toronto ON Canada M5G 2E2
Thank you for taking the time to complete the reference form. If you have any questions, please contact
Registration Inquiries at (416) 967-2617, Monday through Friday 9am to 5pm (EST).
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