Applicant’s Name _________________________________________

Harold Amos Medical Faculty Development Program

CONFIDENTIAL REFERENCE REPORT

TO THE REFERENCE:

This applicant to the Harold Amos Medical Faculty Development Program has named you as one of three references. We ask your cooperation in responding as quickly as possible. Your reference must be postmarked no later than March 13, 2009. To maintain strict confidentiality, return the completed form directly to James R. Gavin III, M.D., Ph.D., Program Director, Harold Amos Medical Faculty Development Program, 714 N. Senate Avenue, EF 212, Indianapolis, IN 46202. Questions may be directed to Nina Ardery at 317-278-0500 or amfdp@indiana.edu.

Reference Name _______________________________________

Title _________________________________________________

Institution ____________________________________________

Telephone (_____) _____________________________________

E-mail _______________________________________________

1. Please evaluate the applicant's performance using the scale below, and using this as the basis of your assessment in Section 3.

0: Unable to judge 1: Poor 2: Fair 3: Excellent 4: Outstanding

Overall preparation for the Harold Amos Medical Faculty Development Program:

Industry/perseverance:

Motivation:

Initiative:

Ability to meet deadlines:

Maturity:

Clinical ability:

Interpersonal facility with peers:

Interpersonal facility with patients:

Demonstrated skill at research:

Potential skill at research:

Integrity:

Judgment/critical sense:

Intellectual ability:

Demonstrated originality:

Potential originality:

Leadership capacity:

0: Unable to judge 1: Poor 2: Fair 3: Excellent 4: Outstanding

Demonstrated productivity:

Potential productivity:

Ability to communicate (written):

Ability to communicate (verbal):

Overall evaluation:

2. Please tell us how long you have known the applicant and in what capacity.

3. Please elaborate on the applicant's performance on the basis of which you arrived at your assessment in Section 1. If possible, please cite some specific illustration of the applicant's performance. Use additional pages if necessary.