EMPA Letter of Recommendation Form

Date:

mm/dd/yyyy

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?

4. Number of rotation:

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

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:

2. Develop differential:

Ability to develop a differential diagnosis and appropriate treatment plan:

3. Communication skills:

Communication skills and intrapersonal interaction:

4. Work Ethic:

Work Ethic?

5. Guidance:

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

6. Overall success:

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

Global Assessment:

1. Comparison:

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

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)

Drop your files here

The candidate has waived his/her right to see this

Electronic Signature:

Send me a copy of my responses