ABMM Reference Form

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This form must be completed by applicant’s current or former immediate supervisor. No letter of recommendation is required.

APPLICANT DATA

First Name*

Middle Inital

Last Name*

Email Address*

Degree

REFERENCE DATA

Reference's First Name*

Reference's Last Name*

Reference's Degree

Reference's Position Title*

Reference's Employer*

Reference's City*

Reference's State/Province

Reference's Country*

Reference's Phone Number

Reference's Business Email - Yahoo, Gmail, or general email addresses (i.e. This email address is being protected from spambots. You need JavaScript enabled to view it.) are not accepted*

Reference's Relationship to Applicant*

How have you overseen the applicant's training and/or experience? (2000 chars left)

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APPLICANT'S POSTDOCTORAL EXPERIENCE IN THE LABORATORY

Applicant's Title (Position Held)*

Applicant's Employer/Institution*

Employer City*

Employer State/Province

Employer Country*

Dates of Applicant's Employment
Leave 'End Date' blank if currently employed. If applicant is a current CPEP Fellow, please indicate his/her expected completion date in the appropriate box above.

Start Date (mm/dd/yyyy)* End Date

Employment Information

In his/her position, does/did the applicant work full-time, at the director-level in a medical, clinical, public health, or reference microbiology laboratory?* Yes No

If employment is/was other than full-time at the director-level, please describe the extent of part-time employment (i.e., the number of hours per week) (2000 chars left)

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Employment Information (continued)

If the applicant completed, or is completing, a training program under your supervision, is the program accredited by the Committee on Postgraduate Educational Programs (CPEP)? Yes No

If the applicant completed, or is completing, a training program under your supervision, is the program accredited by the American Board of Pathology (ABP)? Yes No

If the applicant completed, or is completing, a training program under your supervision, is the program accredited by the Royal College of Physicians and Surgeons of Canada (RCPSC)? Yes No

If you answered “Yes” for one of the three previous questions you may skip the 'Applicant's Duties' section. Press 'Next' at the bottom of the page to proceed.

APPLICANT'S DUTIES

Below, please describe the applicant's duties, giving percentages of time devoted to each of the following areas:
The percentages entered below must add up to 100%.

Responsibilities and skills in the clinical laboratory. Please provide a detailed description below. Description (1000 chars left)

Interaction with healthcare providers. Please provide a detailed description below. Description (1000 chars left)

Management and administrative skills. Please provide a detailed description below. Description (1000 chars left)

Research. Please provide a detailed description below. Description (1000 chars left)

Teaching. Please provide a detailed description below. Description (1000 chars left)

Other. Please provide a detailed description below. Description (1000 chars left)

Total % (must equal 100) Additional Comments

ABMM Reference Form

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