The individual to whom this reference refers has applied for a training placement and has given your name as a referee.  We would be grateful if you could provide us with the information required below.  Please note we can only accept references on this structured reference form.  This professional reference should verify factual information only; we do not require you to provide a personal testimonial or an assessment of the individual. Your responses may be discussed with the applicant named above and/or his/her trainer.  Your reference may also be made available to other departments within the NHS.