ABMM Reference Form

The reference form has moved please go to the ABMM information page and select the "Reference Form" link.

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


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 (Position Held):
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.

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):
 
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

   
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 (50-65%)

(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 (15-30%)

(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 (10-20%)

(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 (0-25%)
(e.g., development/evaluation of new test methods/techniques/ instrumentation; collaboration with clinical/basic research colleagues)
Please provide a detailed description.

Description:
   
%

Teaching (0-25%)
(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.

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