ABMLI Reference Form

Must be completed by applicant’s current or former immediate supervisor.

No letter of recommendation is required.

I. APPLICANT DATA:
First Name:
Middle Initial:
Last Name:

II. REFERENCE DATA:
First Name:
Last Name:
Degree:
Position Title:
Employer:
City:
State:
Country:
Phone Number:
Business Email:
Relation to Applicant:
How have you overseen the applicant's training and/or experience?:
 

III. APPLICANT'S POSTDOCTORAL EXPERIENCE IN THE LABORATORY:
Please complete with the applicant’s information while under your supervision.
Applicant's Title:
Applicant's Employer (Institution):
Employer City:
Employer State:
Employer Country:

Dates of applicant’s employment
(mm/dd/yyyy) to (mm/dd/yyyy):

   to   (leave blank if currently employed)
If applicant is a current CPEP Fellow, please indicate his/her expected completion date in the appropriate box above.
If employment was other than full-time,
please describe the extent of part-time
employment (i.e., the number of
hours per week):
If the applicant completed a training
program under your supervision,
was it accredited by the
Committee on Postgraduate
Educational Programs (CPEP)?
Yes No
If you answered “Yes” you may skip to Section IV: Verification
 
Below, please describe the applicant’s duties, giving percentages of time devoted to each of the following areas. Please specify if the duties were hands-on experience or learned as part of a training program. Refer to the ABMLI eligibility requirements for specific requirements. 
The percentages entered below must add up to 100%.
%
Administrative and Management Activities
Please provide a detailed description
Description:
   
% Diagnostic and Clinical Service
Please provide a detailed description
Description:
   
% Research
Please provide a detailed description
Description:
   
% Teaching
Please provide a detailed description
Description:
% Other
Please provide a detailed description
Description:
% TOTAL
   
Additional Comments: Please provide additional information as to why you would recommend this applicant for certification.  

IV. VERIFICATION
By checking this box, I verify that all the information on this page is complete and accurate to the best of my knowledge.