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CMS Faculty Reference Form

* = required field

Please enter the name of the applicant for whom you've been asked to provide a reference.

Relationship of Reference Source to Applicant

Do you personally know the applicant? *
What type of affiliation have you experienced with the applicant? (check all that apply) *
Do you have any concern of the applicant’s qualifications to meet the required criteria for the proposed rank? (See rank criteria) *

Professional Knowledge, Skills, and Attitude

Please rate the following as Excellent, Good, Average, Below average, or Unable to evaluate.

Medical/Clinical Knowledge *
Communication skills with peers, staff, trainees *
Educational Skills (Classroom, Ambulatory, and/or Bedside Teaching) involving trainees *
Professionalism *


My general recommendation concerning this applicant is: *

Please use this section for any additional comments, information, or recommendations which you believe would be relevant to our decision to grant faculty membership. If you have any questions, please contact our Coordinator, Faculty Appointments whose name and email is listed on the communication which accompanied this form.