BC PHARMACY PRACTICE RESIDENCY PROGRAM
CONFIDENTIAL REFERENCE
To Whom It May Concern:
(name of reference)
Re:
(name of applicant)
The person named above has applied for a position as a pharmacy practice resident in British
Columbia. In order to assist in the selection process, please complete this electronic evaluation
form and return it to Ian.Ayeras@ubc.ca. You may include a separate letter with this form if you
prefer.
If you do not know the applicant well enough to complete the evaluation, or if you know the
applicant well but are unable to comment on a particular attribute, please feel free to indicate this.
At least 3 references are obtained on each of the program applicants; and the references are only
one of several components to the selection process.
Your identity and the information you provide will remain strictly confidential.
Please return this reference by the application deadline
http://pharmsci.ubc.ca/programs/pharmacy-practice-residency
Thank you for your consideration, candor and truthfulness in the completion of this document,
and for your assistance in our selection process.
Sincerely,
Residency Coordinators,
BC Pharmacy Practice Residency Programs
BC PHARMACY PRACTICE RESIDENCY PROGRAM
CONFIDENTIAL REFERENCE FORM
(name of applicant)
Page 1
(name of reference)
1. In what capacity do you know the applicant?
☐ Faculty
☐ Preceptor
☐ Employer
Other:
2. How long have you known the applicant?
☐ Less than one year
☐ One to two years
☐ Three to five years
☐ Greater than five years
3. How many hours per week did you spend with the applicant during this time?
4. On a scale of 0 (lowest) to 5 (highest), please rate the applicant in the following areas:
(Or N/A if unable to assess)
ATTRIBUTES
LEADERSHIP – ability to make decisions, to be
responsible for own actions, to take ownership, and to
lead others
QUALITY – of work, schoolwork, projects; attention to
detail
INDEPENDENCE/INITIATIVE –ability to work
independently and to recognize own limitations;
motivation; self-direction
TIME MANAGEMENT – ability to complete
projects/work within reasonable timeframes, and to
stay focused on the task at hand.
RATING
(0 -5)
ADDITIONAL COMMENTS
BC PHARMACY PRACTICE RESIDENCY PROGRAM
CONFIDENTIAL REFERENCE FORM
ABILITY TO LEARN/PROBLEM SOLVING SKILLS –
ability to integrate knowledge and skills into practice,
to take responsibility for own learning
TEAMWORK – ability to work with others;
commitment to the team and the team’s goals; effect
on others; assertiveness; sensitivity toward others’
needs; ability to energize/motivate others
COMMUNICATION – written and verbal interpersonal
relations with supervisors, subordinates, peers
ADAPTABILITY/FLEXIBILITY – ability to adapt to
changes; acceptance of changes; tolerates ambiguity
DEPENDABILITY/RELIABILITY – ability to see
tasks/projects through to completion; follow-through
on promises, commitments made
JUDGEMENT – ability to make sound assessments
based on appropriate/complete information
PROFESSIONALISM – maturity, emotional stability;
tolerance of stress; self-confidence; response to
feedback
Page 2
BC PHARMACY PRACTICE RESIDENCY PROGRAM
CONFIDENTIAL REFERENCE FORM
Page 3
5. In your opinion, how would you rate this applicant's potential as a health care provider?
Rating [ 0 (lowest) -5 (highest)]:
Comments:
6. Areas of strength:
7. Areas requiring further development:
8. Additional comments/information which you feel are pertinent to the consideration of this applicant:
EVALUATOR INFORMATION:
Name:
Position and Place of Employment:
Address:
Telephone:
Email:
Signature:
(required if not sent via email)
Date:
Please email the form to Ian.Ayeras@ubc.ca.
Thank you for providing this reference.