Center for Clinical Epidemiology and Biostatistics

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Hospital of the University of Pennsylvania
Fellowship in General Internal Medicine and Clinical Epidemiology
Reference Report
Applicant Name:
Referee Name:
Referee Title/Institution:
To the Referee:
The above named applicant is applying for admission into the Fellowship in General Internal Medicine and
Clinical Epidemiology at the University Of Pennsylvania. He/she has identified you as one of his/her
references. Please fill out the below form and attach a letter of recommendation for the applicant. The form
can be completed on the computer but we request that both the form and letter have your signature on it.
Please submit both pages by email/PDF (preferred), fax, or mail:
GIM Fellowship
C/O Elliot Adler
1310 Blockley Hall
423 Guardian Drive
Philadelphia, PA 19104
Tel: 215-573-2740
Fax: 215-573-2742
[email protected]
Please rate the applicant by checking the box in the appropriate column which represents your opinion of the
applicant.
Unable to
Judge
Poor
Fair
Good
Excellent
Outstanding
Overall preparation for fellowship program
Industry/perseverance
Motivation
Initiative
Ability to meet deadlines
Maturity
Clinical ability
Interpersonal facility with peers
Interpersonal facility with patients
Demonstrated skill at research
Integrity
Judgment/critical sense
Intellectual ability
Demonstrated originality
Potential originality
Leadership capacity
Demonstrated productivity
Potential productivity
Ability to communicate (written)
Ability to communicate (spoken)
Likelihood of excelling as an academic faculty member
Overall evaluation
Signature:____________________________________________
Date:____________________________
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