NRCM Reference Form

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I.  APPLICANT DATA

First Name:
Middle Initial:
Last Name:
Email:
 

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

III.  APPLICANT'S EXPERIENCE
Please complete with the applicant’s information while under your supervision.
Applicant’s title (position held):
Applicant’s employer (institution):

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

  to     (leave blank if currently employed)
If employment was other than full-time,
please describe the extent of part-time
employment (i.e., the number of
hours per week):
   

Select what you judge to be the most accurate description of the applicant's employment. (Choose one.)

Research laboratory
Consumer products laboratory
Quality control laboratory
Industrial laboratory
Biological safety
Trainee (Please describe training program in the designated space below.)
Other (Please specify in the box below.)
     
 
   
 
Check the category(ies) that  best describes the applicant's area of employment regardless of his/her occuption title.
General microbiology

agricultural
antimicrobials
clinical/medical
cytology/morphology/cell structure
environmental/aquatic
food production/testing
genetic/molecular/physiological
industrial
taxonomy
veterinary
pharmaceutical


Bacteriology

Biological Safety

Immunology

immunochemistry
immunoserology
molecular
pharmaceutical
research
product development
testing

Mycology

medical/clinical
industrial
pharmaceutical
research
testing

Parasitology

medical/clinical
animal
pharmaceutical
research
testing
product development 


Virology

clinical/medical
bacteria
plant
animal
pharmaceutical
research
testing
other:


Other:
   
   
 

Using the applicant’s job description, estimate the amount of time the applicant devotes to each activity listed below. (The total must equal 100%).

Diagnostic service/training: % Biological safety: %
Analytical service: % Teaching: %
Quality control/quality assurance: % Administration/management: %
Production: % Basic research: %
Inspection: % Applied research: %
Consulting: % Marketing/sales/services: %
Other (please specify in the space to the right): %
 
TOTAL:  %  
   
 

Using the applicant’s job description, describe the applicant’s duties:

   
 
Have any employment activities been:
Concurrent with a formal graduate study program?    no   yes     If yes, please elaborate:
   

Concurrent with a formal training program?   no     yes 

If yes, please include detailed information concerning number of hours employed, type of experience obtained, etc.  
Participation in a training program will be evaluated on an individual basis.

   

IV.  EVALUATION


Evaluate the applicant's capacity to function as a microbiologist within the laboratory OR as a biological safety
officer.  If the applicant is a supervisor, please evaluate his/her supervisory skills as well.

   

V.  VERIFICATION


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

 

SECURITY
Please enter the SECOND, THIRD and LAST
digits in the image to the left.