RD03

PGR Academic Reference Form

_______________________________________________________________________
This form MUST BE SIGNED BY THE REFEREE and may be scanned and emailed to the Research
Student Office at researchoffice@derby.ac.uk Alternatively, please post to Research Student Office,
University of Derby (UoD), Kedleston Road, Derby, DE22 1GB.

Name of Applicant: …………………………………………………………………………………………

Degree to be undertaken: MPhil PhD

Route: Traditional Integrated Published Works

Mode of Study: Full-time Part-time Distance Learning

Please note:
All referees may be contacted to confirm the contents of references.

Within my role as tutor for the applicant, I would evaluate the applicant's academic and research potential as
indicated below:

Category Outstanding Good Average Poor I am unable to

judge
Intellectual
Achievement
Communication
Skills
Analytical ability

Creativity

Self Motivation

Working with Others

Other comments:

Sensitivity: Internal
 (please attach separate sheet/s if required)

Referee’s Name:

Academic Position:

Address:

Telephone:

E-Mail:

Privacy Notice: I declare that I understand that this record will be held for a period of at least 1
year from the date this reference is submitted to UoD; after that time it is destroyed/disposed
of securely.

Referee’s Signature: Date:

PRINT NAME:

April 18

Sensitivity: Internal