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:
Middle Initial:
Last Name:

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

   

In his/her position,
does/did the applicant work full-time in
a clinical, public health, reference,
or other microbiology laboratory?
Yes No
   
If employment is/was other than full-time,
please describe the extent of part-time
employment (i.e., the number of
hours per week):
 
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

(e.g., assisting medical technologists in interpreting the clinical significance of laboratory findings, oversight of quality assurance/quality control,

technical troubleshooting and problem solving)

Please provide a detailed description.
Description:
   
%

Interaction with healthcare providers

(e.g., consultation with healthcare providers regarding the selection

and interpretation of clinical microbiology tests/results; consultation with local and state public health officials; reference lab consultation with clients; participation in hospital/institution committees [infection

control, antibiotic subcommittee, etc.])

Please provide a detailed description.
Description:
   
%

Management and administrative skills

(e.g., interacting with institutional and laboratory administration and personnel; performing financial analyses on new test methods or laboratory programs; assuring/overseeing accreditation, competency, proficiency testing, etc.)

Please provide a detailed description.
Description:
   
%

Research
(e.g., development/evaluation of new test methods/techniques/ instrumentation; collaboration with clinical/basic research colleagues)
Please provide a detailed description.
Description:
   
%

Teaching
(e.g., formal lectures and rounds; resident/fellow/student training)
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.