ABMM Reference Form

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

No letter of recommendation is required.

I. APPLICANT DATA:
First Name:
Last Name:

II. REFERENCE DATA:
First Name:
Last Name:
Position Title:
Employer:
City:
State:
Country:
Phone Number:
Business Email:
Relationship to Applicant:

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, or is completing,
a training program under your supervision, is 
the program accredited by the Committee on
Postgraduate Educational Programs (CPEP)?
Yes No
If you answered “Yes” you may skip the section below.

 
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 (i.e., bench work and interaction with technologists, quality assurance/quality control, and technical troubleshooting and problem solving)
Description:
   
% Interaction and consultation with clinicians
Description:
   
% Management and administrative skills (interaction with institutional and laboratory administration and personnel)
Description:
   
% Other  (Please provide a detailed description.)
Description:
% TOTAL
   
Additional Comments: If you would like to provide any additional information, please do so in the space below. 

IV. VERIFICATION

By checking this box, I verify that I am qualified to provide a reference for this applicant and that all the information on this page is accurate to the best of my knowledge.