Graduate Certificate in Academic Medicine

GCAM Reference form


This form is considered part of the student's application materials and is required before action can be taken with regard to the student’s applicant status. Any information you provide is protected by the 1974 Family Educational Rights and Privacy Act (FERPA). These recommendations must address the applicant’s abilities engaging in analytical and critical thinking, writing at a graduate level, and using technology to complete course-related projects.
Applicant’s Name:
Recommender’s Name:
Recommender’s Title:

1. I have known the applicant for,

2. I know the applicant:

3. I have known the applicant (check all that apply):
In an educational setting:
In a work setting:
In a work setting:

4. Compared to other health professionals of like training, rate this applicant on each characteristic:
Emotional maturity
Ability to work with others
Leadership skills/qualities
Flexibility and adaptability
Intellectual curiosity
Writing ability
Speaking ability
Problem-solving ability
Professional commitment

5. Recommendation (check one):

For more information, please contact the Faculty Development Center at
This field is for validation purposes and should be left unchanged.


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