GEN1

Employer’s reference

Who completes the form?

This form is to be completed by a Human Resources representative or the applicant’s line manager (for example current
clinical/educational supervisor). It should not be completed by the applicant.

How should the form be submitted?

Please send the form directly to us by email, ensuring that you include the applicant’s name and GMC reference number
in the subject line. We only accept forms by email and from professional email addresses. We do not accept them from
personal webmail accounts such as hotmail, yahoo or gmail.

If you do not have a professional email address, please include a supplementary cover sheet on official letterheaded
paper which also includes an official stamp.

Please note that a copy of the completed reference will be shared with the applicant.

Employer concerns - what you need to tell us about in section 2 of this form

We only need to know about concerns that led to a formal process. If someone has raised a concern about the applicant’s
character, conduct or fitness to practise, and this led to a formal process you should inform us of this.

Concerns could be raised if anything happens during the applicant’s employment that falls below your expectations and
might include:

• Abuse of professional position

• Bullying or harassment of others

• Discrimination against others

• Fraud or dishonesty

• Failure to meet expected performance objectives

• Serious breaches of confidentiality

If the concern raised led to a formal process, this should be recorded in this form. Examples of a formal process could
include any of the following where an applicant has been:

• Issued with formal written notification(s) about concerns

• Excluded from work while under investigation

• Invited to attend a formal hearing

You don’t need to tell us about verbal warnings or if a formal process is finished and no action was taken because the
concerns were not substantiated.
Section 1 – applicant’s details

Applicant’s name

Applicant’s GMC reference number

Period of employment

From D D M M Y Y Y Y To D D M M Y Y Y Y

Position held by applicant (please include

their speciality if appropriate)

Average number of hours undertaken per

week

Please give a description of duties.

Section 2 – to be completed by all employers

Are you aware of any issues that would call into question the applicant’s character,
conduct or fitness to practise? yes no
(For example, were they subject to any disciplinary proceedings whilst employed by you?)

If ‘yes’, please provide details.

Last updated on 19/4/2023. Please make sure you are using the most up-to-date version of the form. GEN1

W: www.gmc-uk.org T: 0161 923 6602 (+44 161 923 6602 when calling from outside the UK) Page 2 of 5
Section 3 – to be completed by all employers

Question 3a
Was the applicant working in a clinical medical capacity? (Please note that clinical
attachments and observer posts are not considered to be clinical practice) yes no
If ‘no’, please go to Question 3b. If ‘yes’, please go to question 3c.

Question 3b
For non-clinical posts that are medically related (for example a teaching or research post):
Please confirm whether this role was restricted to a holder of an MBBS or equivalent (for
example, MD or MBChB)
yes no
Please note, if other candidates are/were also eligible for this post – for example health
care professionals or holders of alternative qualifications (for example BSc or Masters)
you should answer ‘no’.

If ‘yes’, please provide a comprehensive summary of the applicant’s job description and their duties

Question 3c

Was the applicant required to hold registration or a licence to practise with a medical
yes no
regulator?

If ‘yes’, please give us the name of the relevant medical regulator and confirm the type of registration required. For
example, provisional or full registration, with or without a licence to practise.
Please provide the name of the authority that regulates doctors in the country or region the applicant was/is working in
(for example General Medical Council, UK). Do not provide the name of an individual person.

Last updated on 19/4/2023. Please make sure you are using the most up-to-date version of the form. GEN1

W: www.gmc-uk.org T: 0161 923 6602 (+44 161 923 6602 when calling from outside the UK) Page 3 of 5
If ‘no’, please explain why the applicant was allowed to work in a medical capacity without holding registration or a licence
with the appropriate medical regulator.

Section 4 - declaration

Your name

Your position

Please confirm whether you are related to

the applicant If yes, please state the
relationship (for example: ‘father’)

Website address for your organisation

Your work email address

This should be an official work email address not a webmail address such as yahoo, hotmail or googlemail. If your work
email is a webmail address, please return this form and a copy of your official letter head and stamp.

Telephone number

This should be an official work telephone number, not a personal home telephone number. Pleased provide landline and
mobile numbers.

Last updated on 19/4/2023. Please make sure you are using the most up-to-date version of the form. GEN1

W: www.gmc-uk.org T: 0161 923 6602 (+44 161 923 6602 when calling from outside the UK) Page 4 of 5
Section 4 - declaration (continued)

Your signature

Date D D M M Y Y Y Y

Name and address of organisation Official stamp

Last updated on 19/4/2023. Please make sure you are using the most up-to-date version of the form. GEN1

W: www.gmc-uk.org T: 0161 923 6602 (+44 161 923 6602 when calling from outside the UK) Page 5 of 5