OP29 Structured Reference Form

Joint Committee on Intercollegiate Examinations
Structured Reference Form

(to be read in conjunction with Guidance Notes for Referees and examination Regulations)
Section A – to be completed by Applicant

Specialty
Examination Date
Examination Closing Date for Applications
Applicant’s Last Name
Other Names in full
Home Address
Postcode
GMC/IMC Number
Date of Birth (day/month/year)
Sections B – H inclusive – to be completed by Referee

Guidance for Referees:
 UK & Republic of Ireland Trainees:
• The Training Programme Director (i.e. Principal Referee) confirms that the applicant has acquired the applied knowledge and clinical skills
to be assessed at the level of a Day 1 Consultant in the generality of the Specialty
• The applicant must satisfy one of the following criteria:
o Completion of Phase 2 of the relevant specialty curriculum with an ARCP Outcome 1
o Be a maximum of 2 WTE clinical years in advance of the indicative CCT/CCST date and have an ARCP Outcome 1 at that point in
training
 If the applicant is not on a training programme then you must be satisfied that the applicant has equivalent experience at the level stated
above for UK and Republic of Ireland trainees and has had specific training in the areas of surgical practice which will be examined in the
Section 2 component of the examination and satisfies all the criteria as defined in the Guidance Notes for Applicants.
 The applicant has, in the last 4 years, undertaken appropriate training in those areas of surgical practice that will be examined in the Section 2
component of the examination.
 The applicant regularly attends the Higher Surgical Training Programme and/or has attended appropriate training courses and has knowledge
of the literature relevant to the specialty.
Information on poorly performing candidates will be fed back to referees. Signing up an applicant who does not meet the above criteria and whose
performance in the examination is excessively poor could be perceived as a potential probity issue for the referee with regard to patient safety.
Section B
Referee’s Name
Position
GMC/IMC Number
Hospital Address
Post Code
Telephone
Mobile
E-mail
Please tick relevant box(s)
Programme Director Clinical/Medical Director
Consultant Trainer Head of Department
Supervising Consultant
Senior Colleague on UK/Irish Medical Register
Chairman/Member Regional Training Committee
Joint Committee on Intercollegiate Examinations

Policy No. OP29 v5.0
Date of last review: Aug 2023
My detailed comments on the above applicant’s suitability to take this examination are as follows:
Section C – Diagnostic Skills [See accompanying Guidance Notes on Diagnostic Skills]
Section D – Clinical Management [See accompanying Guidance Notes on Clinical Management]
Section E – Technical Operative Skills [See accompanying Guidance Notes on Technical Operative Skills]
Section F – Professionalism & Probity [See accompanying Guidance Notes on Professionalism]
Section G – Communication & Language Skills [See accompanying Guidance Notes on Communication & Language Skills]
Declaration
I declare that: please


1. I confirm that my name appears on the UK or Irish Medical Register
2. I confirm that I have read and understood the standards set out in the Guidance Notes for Referees and the relevant general and
specialty-specific standards set out in the Intercollegiate Surgical Curriculum for the award of the Certificate of Completion of Training
(CCT) by the GMC or the award of Certificate of Completion of Specialist Training (CCST) by the Royal College of Surgeons in Ireland and
have completed this structured report with reference to those standards.
3. I confirm that I have direct knowledge of the applicant’s current clinical practice within the last 2 years
[applicable to all referees except Training Programme Directors].
4. I confirm that I am the applicant’s Training Programme Director and confirm that:
• the applicant has acquired the applied knowledge and clinical skills to be assessed at the level of a Day 1 Consultant in the
generality of the Specialty
• The applicant satisfies one of the following criteria:
o Has completed Phase 2 of the relevant specialty curriculum with an ARCP Outcome 1
o Is a maximum of 2 WTE clinical years in advance of the indicative CCT/CCST date and has an ARCP Outcome 1 at that point
in training
[applicable to Training Programme Directors only]
5. I confirm that I have examined the applicant’s portfolio including logbook and summary of operative experience and that this is
commensurate with a UK or Ireland trainee within 2 years of CCT or CCST respectively.
6. I accept that I have a responsibility to the profession and confirm that the information contained in this reference is true and accurate
and referenced to Good Medical Practice.
7. I confirm that, to the best of my knowledge, the information I have given in this structured reference is true and accurate. I understand
that it will be used by the Intercollegiate Specialty Board in its evaluation of this doctor’s application for entry to the Intercollegiate
Specialty Examination.
Section H
I confirm that I am , the sponsoring referee named above and have no reservations about this candidate’s
application for entry to the examination.
Date:
For Applicants not in a Training Programme (to be completed for the Principal Referee Statement Only)
UK Applicants: I confirm that I am the Director of Medical Education or Nominated Deputy in the applicant’s place
of employment, that this referee statement has been completed by an appropriate individual, that the applicant
has complied with annual appraisal and has no restrictions on his/her clinical practice. Applicants must have the
Principal Referee form countersigned before the applicant submits it to the JCIE.
Republic of Ireland Applicants: On behalf of the Royal College of Surgeons in Ireland I confirm that this referee
statement has been completed by an appropriate individual, that the applicant has complied with maintenance of
professional competence and that he/she has no restriction on clinical practice. Applicants must send the signed
Principal Referee form to [email protected] to have it countersigned by RCSI before the applicant submits it to
the JCIE.
Name: Signature:
Designation: Date:
It is the applicant’s responsibility to ensure that all 3 references are uploaded at the time of online application.

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Joint Committee on Intercollegiate Examinations

Structured Reference Form

Section A – to be completed by Applicant

Sections B – H inclusive – to be completed by Referee

Joint Committee on Intercollegiate Examinations

Section C – Diagnostic Skills [See accompanying Guidance Notes on Diagnostic Skills]

Section D – Clinical Management [See accompanying Guidance Notes on Clinical Management]

Section F – Professionalism & Probity [See accompanying Guidance Notes on Professionalism]

I declare that: please

1. I confirm that my name appears on the UK or Irish Medical Register

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