Please complete this form as completely as possible. Most fields require a response. Omissions or inaccurate information will delay applicant’s approval. Your submission of this form is greatly appreciated. Name and degree of individual completing this reference form (John Doe, MD). * Please provide your professional position and the institution where you hold this position.(Chair Dept of Surgery, Chief Division of Neurosurgery, ABC Hospital or University, etc.): Address of individual completing this form (City, State and Zip). * Please provide your email address in case we need to contact you. * Please provide your cell phone number in case we need to contact you? Name of AANOS applicant as indicated on the email directions you received. * What is/was your professional relationship with the applicant? * How long have you known this individual? * What is the applicant’s primary specialty? * Secondary Specialty? During the time that you have known the applicant, to your knowledge, has the applicant ever:1. …had their medical, pharmacy, or DEA license reclassified, suspended, restricted or revoked? * Yes No 2. … had a physical, emotional, alcohol/substance abuse problem that may impair their judgement or performance? * Yes No 3. …been subject to a disciplinary action by a medical society, hospital, or board? * Yes No 4. …had their privileges, medical or surgical, been revoked or curtailed by any hospital? * Yes No If the answer to any of the previous 4 questions was YES, you must provide a detailed explanation in the field below. RECOMMENDATIONPlease select one: * Recommend highly without reservation Recommend as qualified and competent Recommend with some reservation (Please provide comments below) Do not recommend (Please provide comments below) The information I have provided is based on: * Close and personal observation General impression Composite evaluation Other (Explain in comments below) Members of the AANOS are eligible to apply for certifications offered by the American Federation for Medical Accreditation (AFMA). If the candidate applies for certification by an AFMA Board, do you believe that they have adequate training and experience to take the written and oral examinations in their specialty? * Yes No (Please explain in comments field.) Please list applicant’s strengths and weaknesses, and/or provide explanation(s) of previous response(s): Certification and Signature: I hereby certify that the information I have provided in this reference form is to my knowledge true and accurate. There is no ill intent or bad faith involved in my support of the indicated candidate. My digital signature below is confirmation of the information I have provided and any statements I have made pertaining to the applicant. Type in your name in the field below. By doing so you agree this is a legal substitute for your signature. * Enter today’s date. * If you are human, leave this field blank. Δ
