EMPA Letter of Recommendation Form

EMPA Letter of Recommendation Form

Date:*

Applicant Name:*

Reference provided by:*

Present position:*

E-mail:*

Institution:*

Telephone:*

Background:

1. Known Applicant:*

How long have you known the applicant?

2. Nature of contact:*

Nature of contact with applicant (PA program director, instructor, mentor/advisor, colleague):

3. Rotation at your institution:

If this applicant rotated in your EM department, what was his/her grade?

Select or enter value

4. Number of rotation:

Was this the first or second EM rotation for the applicant?

Select or enter value

5. Rotation Dates:

Rotation Dates?

Candidate Qualifications:

Please compare the candidate to other PA students with intention of entering EM

1. Commitment to EM:*

Commitment to emergency medicine, and careful thought about field choice:

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2. Develop differential:*

Ability to develop a differential diagnosis and appropriate treatment plan:

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3. Communication skills:*

Communication skills and intrapersonal interaction:

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4. Work Ethic:*

Work Ethic?

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5. Guidance:*

How much guidance do you think this candidate will require during residency?

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6. Overall success:*

Given this amount of guidance, what do you think is the overall chance of success for the applicant?

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Global Assessment:

1. Comparison:*

Compared to other PA candidates you have recommended, this applicant is considered:

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2. Refered candidates:*

How many candidates have you referred to an EM PA residency?

3. Additional coments:*

What would you like us to know about the candidate? (feel free to continue on a word document and upload it as an attachment)

File Attachments

Drag and drop files here or

The candidate has waived his/her right to see this*

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Electronic Signature:*

Send me a copy of my responses

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