MRCPsych CASC Examiner Confidential Reference

MRCPsych CASC Examiner Reference Form

Please complete the following questions.

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* 1. Confidential reference supplied on behalf of: (Applicant’s Name)

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* 2. Your details - Forename

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* 3. Your details - Surname

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* 4. Email address

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* 5. RCPsych number

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* 6. GMC number

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* 7. Membership status

Member

Fellow

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* 8. Job title

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* 9. Employer details

Name

Company

Address

Address 2

City/Town

Postal Code

Country

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* 10. Date of appointment

Please enter date of appointment

Date

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* 11. Please indicate if you support this applicant being appointed to the Board of Examiners of the College:

I support this candidate for appointment to the Board of Examiners of RCPsych

I do not support this candidate for appointment to the Board of Examiners of RCPsych

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* 12. Please give your reasons: Reasons should focus on the applicants work, training, educational and examination related activities.

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* 13. Are you aware if the applicant is subject to any complaint, investigation, disciplinary or professional proceedings?

Yes

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* 14. If yes please give details

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* 15. Please indicate the capacity in which you are completing this reference:

Member of the Education, Training and Standards Committee

Member of the Examinations Committee

Professor of Psychiatry

Head of School of Psychiatry

Director of Medical Education within the applicant's Trust/Hospital

The Training Program Director - regional or in the training scheme where applicant works

The Lead for Undergraduate Education for the applicant's Trust/Hospital

A Regional Adviser

Chair of a Division, Faculties or Section of the College

Chair of a Regional Training Committee

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* 16. I declare that to the best of my belief the information provided by me on this form is accurate. I understand that the information given in this form may be provided to members of the Examinations Sub-Committee of the Royal College of Psychiatrists, in strictest confidence, for the purpose of appointing to the Board of Examiners. I consent to the College processing the information I have provided, by any means, and its use as described for the purpose of appointing to the Board of Examiners.

Yes