REFEREE FORM – CLINICAL RADIOLOGY

Notes for Referees

This Referee Form is part of the national recruiting program, administered by RANZCR’s New Zealand Office.
Successful applicants will be enrolled for training positions within the Royal Australian and New Zealand
College of Radiologists (RANZCR).

Before you complete this form, please note:

• Referees must be independent of the applicant, with no conflict of interest.
• Referees cannot be radiologists.
• During the period you supervised the applicant in New Zealand, you must have held either a provisional
vocational or vocational scope of practice. If you supervised the applicant outside of New Zealand, you must
have held specialist registration in that jurisdiction.
• References must be from a specialist with whom the candidate has actually worked. A specialist who knows
the applicant and might have spent some time with them during department visits is not appropriate to
provide a reference.
• Information provided by Referees in relation to the applicant may be accessible by the applicant, at their
request.
• References are a critical part of the candidate’s application, so please ensure that a signed copy
(electronic signatures are accepted) of this form is emailed directly to nzrecruit@ranzcr.org.nz

Please send your completed form to:

Email: nzrecruit@ranzcr.org.nz
Subject: Clinical Radiology Training Reference

A. REFEREE DETAILS
Please supply information about yourself, as we may contact you to further discuss the applicant.
Full name:

Current position held:

Hospital/Department:

Contact details: Work phone:

Mobile phone:

Email:

Do you hold either a provisional vocational or a vocational scope of practice? (If you are not practising
in New Zealand, are you registered with your regulatory authority as a specialist?)
Yes No

B. APPLICANT DETAILS
Please supply the name of the person you are providing this reference for.
Name of applicant:

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1. PROFESSIONAL RELATIONSHIP WITH THE APPLICANT
a) How long have you known the applicant?
Less than 1 year 1-2 years 2–5 years Over 5 years
b) In what capacity have you worked with the applicant?

2. PERSONAL EVALUATION OF THE APPLICANT

a) What are the applicant’s strengths?

b) What are the applicant’s weaknesses?

c) Did you have any issues working with the applicant?

d) Why would the applicant make a good Clinical Radiologist?

e) Do you have any concerns as to the applicant’s suitability to train in Clinical Radiology?

f) Do you have any comments to make about the applicant in relation to the following?
i. Ability to work in a team

ii. Reliability

iii. Problem solving skills

g) At his/her/their current level of seniority, how happy would you be for the applicant to treat you
or a member of your family? Please highlight the appropriate number box, below.
1 2 3 4 5 6 7 8 9 10

Not happy Happy Extremely happy

h) How keen would you be to enrol the applicant into the training scheme for your specialty?
Please highlight the appropriate number box, below.
1 2 3 4 5 6 7 8 9 10

Not happy Happy Extremely happy

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3. EVALUATION OF THE APPLICANT’S PERFORMANCE
a) Please assess the applicant’s performance based on a comparison between the applicant and
others whom you have supervised at a similar level. Use the criteria below:
Criteria Bottom 10% 10-30% 30-70% 70-90% Top 10%
Ability
• Theoretical knowledge
• Clinical judgement
• Willingness to learn
• Application to work
• Medical records
• Punctuality
• Potential for the future
Rapport and interaction with others
• Patients & family
• Medical Staff
• Other staff and teams
Ability to communicate in English
• Written
• Oral

b) Please indicate what your assessment (above) is based on by ticking the appropriate box below:
Close personal observation General impressions Observations from team members

4. THE FOLLOWING QUESTIONS ARE REQUIRED IN ACCORDANCE WITH THE PROVISIONS OF

THE VULNERABLE CHILDREN ACT (VCA) 2014
Do you consider the applicant suitable to work with children? If not – why not?
(NB for the VCA a child is aged between 0-16 years)
Yes – they are suitable to work with children

No – (If no, please provide details below)

N/A –I have not had the opportunity to observe the applicant with children up to the age of 16 years.

Details:

5. THE FOLLOWING SERIES OF QUESTIONS IS AIMED AT ESTABLISHING WHETHER OR NOT

THE APPLICANT IS APPROPRIATE TO WORK IN A POSITION INVOLVING CHILDREN
Has the applicant ever been disciplined for misleading or fraudulent conduct relating to a child?
Yes No

Was the applicant ever subject to formal disciplinary action or complaints regarding their disciplinary
techniques towards children?
Yes No

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6. GENERAL COMMENTS
Please provide any additional information that you believe is relevant.

7. DECLARATION
Please indicate whether (or not) this reference can be:
a) Released in confidence to a prospective employer within New Zealand, if the application for a Clinical
Radiology training post is successful.
Yes No

AND

b) Retained in confidence by the College for release to a prospective employer within New Zealand in the
event of a casual vacancy, if the application for a Clinical Radiology training post is unsuccessful.
Yes No

Signature: Date: / /

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