NSW Health Locum Reference Check

Thank you for taking the time to complete this reference check, which is an important part of our quality recruitment process. The questions in this check are devised by the NSW Health Department specifically for the employment of locums in NSW.

Please note that the responses that you provide will be placed on the candidate's file, which they can access upon request, in accordance with the Privacy Act. The information that you provide will be given to potential employers. 

Please call us on +61 2 8014 0175 if you have any questions about this reference check.

* Required fields <>

Candidate Name *
Facility *
Title	DR MISS MR MRS MS
Your Name *
Last Name *
Email Address *
Your position *
Department *
Direct contact number *
Mobile Number
Fax Number
Today's date *
How long did you work with the candidate? *
Responses are based upon *	Direct observation Review of accumulated information
Time period (from-to) *
Setting/Facility *	-- Please select -- Ward Emergency Department Community Other
Would you use this medical officer again? *	-- Please select -- On preferred list With hesitation
If "with hesitation", why?
What are his/her strengths? *
Does he/she ask for assistance if needed? i.e. knows their own limitations. *
How well does she/he handle pressure or a busy workload? *
How would you describe his/her communication and interpersonal skills? With patients and staff? *
Is he/she a strong team player, and works well in team situations? *
How flexible is she/he? How would you see them adapting to a new workplace? *
Area you aware of any disciplinary action or legal proceedings against the Medical Officer? *	-- Please select -- Yes No
Are there any issues which may impact on their work that we should be aware of? *	-- Please select -- Yes No
Any further comments?
The next part of the reference check relates specifically to the candidate's clinical skills. Please provide your responses based on your own observations, or reports from others. If you are unable to provide a response, please select "Unsure".
GENERAL RESIDENT *	-- Please select -- Not observed Capable (own observations) Capable (other observations) Unsure
General medical abilities as a resident/senior resident medical officer to work under supervision.  This must include understanding of own limitations and when to ask for assistance, and including (not exhaustive) proficiency in peripheral venous cannulation, arterial blood gas sampling, urethral catheterisation, ECG interpretation, lumbar puncture, use of fluids & blood products, simple suturing.
IN-CHARGE *	-- Please select -- Not observed Capable (own observations) Capable (other observations) Unsure
Able to prioritise, know own limitations & ask for help where appropriate, can communicate severity appropriately over the phone, and can supervise others (particularly the type of skill to be in charge of a department, or hospital)
BASIC PAEDIATRIC SKILLS *	-- Please select -- Not observed Capable (own observations) Capable (other observations) Unsure
Basic paediatric care – general abilities to assess children having completed a paediatric resident term, or seen children in a mixed emergency department.  Includes peripheral venous cannulation in children.
EMERGENCY MEDICINE *	-- Please select -- Not observed Capable (own observations) Capable (other observations) Unsure
Able to correlate history, examination and diagnostic tests in order to make provisional diagnosis & initiate management for most presentations to the emergency department.  This includes (but not exclusive to) ability to manage multisystem trauma, management of simple fractures & dislocations, complex suturing, use of slit lamps and ENT instruments for removal of foreign bodies.
ICU MEDICINE *	-- Please select -- Not observed Capable (own observations) Capable (other observations) Unsure
Mechanical ventilation can generally function at the level of a registrar in intensive care.
INTERNAL MEDICINE ADULT*	-- Please select -- Not observed Capable (own observations) Capable (other observations) Unsure
Able to correlate history, examination and diagnostic tests in order to make provisional diagnosis & initiate management for patients admitted or proposed to be admitted under an adult physician.  Must have at least 6 months experience functioning as a medical registrar or equivalent.
PSYCHIATRY *	-- Please select -- Not observed Capable (own observations) Capable (other observations) Unsure
Minimum of 6 months experience as a psychiatry registrar, sufficient knowledge about mental health to be able to make independent clinical decisions and in particular current knowledge of the Mental Health Act & function in a multidisciplinary team.
SURGERY *	-- Please select -- Not observed Capable (own observations) Capable (other observations) Unsure
Minimum of 6 months experience as a surgical registrar in a relevant surgical subspecialty, with sufficient knowledge to make independent decisions, & recent experience in Trauma call teams
MANUAL VENTILATION - ADULT:*	-- Please select -- Not observed Capable (own observations) Capable (other observations) Unsure
Manual ventilation (e.g. bag & mask ventilation, Guedels airway, laryngeal mask airway – adult)
UNCOMPLICATED INTUBATION – ADULT:*	-- Please select -- Not observed Capable (own observations) Capable (other observations) Unsure
Uncomplicated intubation of an unconscious adult patient
DIFFICULT INTUBATION - ADULT:*	-- Please select -- Not observed Capable (own observations) Capable (other observations) Unsure
Difficult intubation
CPAP *	-- Please select -- Not observed Capable (own observations) Capable (other observations) Unsure
BiPA*	-- Please select -- Not observed Capable (own observations) Capable (other observations) Unsure
INTERCOSTAL CATHETER INSERTION *	-- Please select -- Not observed Capable (own observations) Capable (other observations) Unsure
CENTRAL LINE INSERTION *	-- Please select -- Not observed Capable (own observations) Capable (other observations) Unsure
ARTERIAL LINE INSERTION *	-- Please select -- Not observed Capable (own observations) Capable (other observations) Unsure
VASOACTIVE DRUGS: Use of vasoactive drugs *	-- Please select -- Not observed Capable (own observations) Capable (other observations) Unsure
CARDIOVERSION & DEFIBRILLATION:*	-- Please select -- Not observed Capable (own observations) Capable (other observations) Unsure
Emergency cardioversion & defibrillation
EXTERNAL PACING *	-- Please select -- Not observed Capable (own observations) Capable (other observations) Unsure
PERICARDIOCENTESIS *	-- Please select -- Not observed Capable (own observations) Capable (other observations) Unsure
PAED MANUAL VENTILATION:*	-- Please select -- Not observed Capable (own observations) Capable (other observations) Unsure
Includes bag & mask in children
ADV PAED LIFE SUPPORT:*	-- Please select -- Not observed Capable (own observations) Capable (other observations) Unsure
Experience in advanced paediatric resuscitation & life support
PAED INTEROSSEOUS LINES:*	-- Please select -- Not observed Capable (own observations) Capable (other observations) Unsure
Experience in inserting interosseous lines into acutely unwell children
PAED ABG: experience in paediatric blood gas sampling *	-- Please select -- Not observed Capable (own observations) Capable (other observations) Unsure
NEONATAL MANUAL VENTILATION: (e.g. Bag & mask, neopuff) *	-- Please select -- Not observed Capable (own observations) Capable (other observations) Unsure
NEONATAL RESUSCITATION:*	-- Please select -- Not observed Capable (own observations) Capable (other observations) Unsure
Experience in the acute resuscitation of neonates, including intubation & ventilation
NEONATAL BLOOD GASES: *	-- Please select -- Not observed Capable (own observations) Capable (other observations) Unsure
NEONATAL CANNULATION:*	-- Please select -- Not observed Capable (own observations) Capable (other observations) Unsure
Can place peripheral venous cannulas in neonates
NEONATAL UMBILICAL LINES:*	-- Please select -- Not observed Capable (own observations) Capable (other observations) Unsure
Experience in placement of umbilical venous lines
NEONATAL ADVANCED SKILLS:*	-- Please select -- Not observed Capable (own observations) Capable (other observations) Unsure
Includes mechanical ventilation & insertion of intercostal catheters
Enter Word Verification in box below *