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Reference Form for Nursing Educational Award

NOTE: You must use Chrome browser to print this form.

Please complete and print form, seal in an envelope, sign the seal and return to student to include in packet.

Applicant's Name

Applicant's First Name

Last Name

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Reference Name

Reference First Name

Last Name

Reference E-mail Address

Relationship

Reference directions: The above Nursing Educational Awards applicant has selected you to provide a reference. Please choose one of numbers (1-5) for each category to reflect your assessment of the applicant. If you have no basis for making a judgment, please choose “cannot judge".

Attributes

(Numerical Rating of Attribute) 1: Inadequate 2: Below Average 3: Satisfactory 4: Above Average 5: Outstanding

Initiative

1. Requires detailed instruction; dependent on others

2. Frequent supervision required; relies on others for direction

3. Routine worker; requires supervision on new tasks

4. Resourceful; independent; paces self

5. A self-starter; seeks additional tasks

Cannot Judge

Communication

1. Difficulty communicating ideas and intentions to others

2. Acceptable communication under normal conditions

3. Communicates clearly under usual circumstances

4. Communicates clearly under unusual circumstances

5. Clear expression of ideas even under stress

Cannot Judge

Organization

1. Unable to prioritize tasks; disorganized work habits

2. Variable efficiency in managing tasks

3. Reorganizes efficient ways of accomplishing tasks with some direction

4. Organizes work and accomplishes tasks with minimal direction

5. Prioritizes and accomplishes tasks independently

Cannot Judge

Judgment

1. Poor judgment; likely to make illogical decision

2. Fair judgment under normal circumstances; sometimes acts before thinking

3. Judgment good on routine matters

4. Thinks clearly and positively under unusual conditions

5. Logical; sound judgment

Cannot Judge

Adaptability

1. Has considerable difficulty in adjusting to any assignments

2. Has some difficulty when shifted to new/different assignments

3. Average amount of guidance needed to learn variety of duties

4. Usually learns new assignments with normal supervision

5. Highly flexible; can handle many varied assignments

Cannot Judge

Dependability

1. Unreliable; needs detailed supervision and follow up

2. Somewhat unreliable; requires occasional check on routine tasks

3. Usually can be depended upon, but more guidance needed on important matters

4. Usually meets responsibilities carefully and correctly

5. Merits utmost confidence

Cannot Judge

Additional comments: (Please limit text to no more than three lines.)

To print page hit the keys [Ctrl or Command] + [P]

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Use Self-Scheduling to book a primary care appointment online

Schedule now!

Reference Form for Nursing Educational Award

NOTE: You must use Chrome browser to print this form. Please complete and print form, seal in an envelope, sign the seal and return to student to include in packet.

Attributes

NOTE: You must use Chrome browser to print this form.

Please complete and print form, seal in an envelope, sign the seal and return to student to include in packet.