1. REFEREE REPORT FORM - CONFIDENTIAL
NOTE: Referee Reports are subject to Right to Information Act 2009 (RTI) and Information Privacy Act 2009 (IP) and the
Queensland Health Recruitment and Selection B1 Policy: http://www.health.qld.gov.au/qhpolicy/docs/pol/qh-pol-212.pdf.
To complete electronically please double click on the appropriate box and then mark the "checked" box
Candidates Name (person you are
supplying reference for):
Chi Tsang
Referees Full Name & Title: Rebecca Strutt
Referees Hospital/Healthcare Facility: Liverpool hospital SWSLHD
Referees Position: Senior staff specialist
Phone: 0434567649 Email: Rebecca.strutt@sswahs.nsw.gov.au
This reference is based on
(tick all boxes that apply):
General Information, Direct Observation, Feedback from Registrars,
Collective opinion of Consultants, Feedback from Directors of Training
1. Professional Relationship
How long have you worked
with/supervised the candidate?
1 year or less 2 yrs 3yrs +
Candidates level at the time of
supervision: (Please assess only at the
level YOU have observed this candidate)
Medical Student PGY1 PGY2 PGY3+
Relationship to Candidate: (eg.
Supervisor, Educational, Director of
Department)
Supervisor for Independent Learning Project
What was your position at the time of
supervision of the candidate?
Senior staff specialist
Term Supervised (e.g. General
Medicine)
Independent learning project in year 4
When was your last professional contact
with the candidate?
6 months ago
Rating Scale Performance Criteria:
Requires
substantial
assistance
Requires
further
development
Consistent
with level of
appointment
Performance
better than
expected
Performance
exceptional
N/A Not
observed
2. Clinical Skills & Knowledge Base (please tick the appropriate box)
History-taking, physical examination &
presentation of findings
Clinical knowledge
Clinical judgement & decision-making
skills
Procedural skills (bearing in mind
candidates level of experience) eg ability
to provide Basic & Advanced Life
Support &/or cannulation using aseptic
technique
Demonstrated knowledge of own
limitations
3. Professional & Ethical Behaviour (please tick the appropriate box)
Punctuality & reliability (completion of set
tasks on time)
Time management
Initiative & responsibility for actions
Demonstrates respect for all /
demonstrates empathy
Queensland Health Referee Report Page 1 of 2

2. Rating Scale Performance Criteria:
Requires
substantial
assistance
Requires
further
development
Consistent
with level of
appointment
Performance
better than
expected
Performance
exceptional
N/A Not
observed
4. Communication & Interpersonal Skills (please tick the appropriate box)
Communication & rapport with patients
and families
Relationships & communication with
other health professionals
Clarity of medical records
Promptness & clarity of discharge
summaries and letters
5. Teaching & Learning (please tick the appropriate box)
Participation in education & professional
development
Participation in research
Participation in teaching of others
Participation in audit/quality improvement
processes
6. Leadership & Teamwork (please tick the appropriate box)
Demonstrated effective clinical
leadership
Effective and valued team member
7. Employability
Are you aware of any formal complaints, disciplinary or legal action against the candidate? Yes No
Would you offer this candidate another post in your unit, either as a locum or medical practitioner? Yes No
Please provide a comment on your
response.
Would you entrust the care of a member of your family to the candidate? Yes No
Please provide a comment on your
response.
8. Conflict of Interest & Other Comments
Do you have a personal relationship with the candidate or any conflict of interest in providing this
reference?
Yes No
If yes, please provide details:
9. Other
Please provide any other comments
regarding the candidate that you may
wish to make.
I declare that I have sufficient knowledge of the medical candidate performance to
provide the ratings and comments above.
Typed signature will be regarded as referee’s tacit signature and will be verified by medical recruiters at the relevant facility.
Referee: Date:
Thank you for your time and valued response
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