Contact and Applicant Information

Clinical Faculty Name and Title

E-mail Address

(Remember: You must use the form your name@somesite.com)

Phone Number

Company or Institution

(Please make sure that your contact information is correct so that we many contact you if we have questions about your reference.)

Who is applying for this position?

In what clinical/classroom setting have you observed this student?

Applicant Rating

Please rate the applicant on a scale of 1 to 5, with 5 being the best. If you don't have information on any item, please choose "Not Applicable (NA)".

Overall Quality of Work

1 2 3 4 5 NA

Basic Nursing Skills

1 2 3 4 5 NA

Attention to Detail

1 2 3 4 5 NA

Customer Service Skills

1 2 3 4 5 NA

Attitude

1 2 3 4 5 NA

Leadership

1 2 3 4 5 NA

Critical Thinking Skills

1 2 3 4 5 NA

Energy

1 2 3 4 5 NA

Teamwork

1 2 3 4 5 NA

Collaboration

1 2 3 4 5 NA

Interpersonal Skills

1 2 3 4 5 NA

Integrity

1 2 3 4 5 NA

Dependability

1 2 3 4 5 NA

Appearance

1 2 3 4 5 NA

Overall Recommendation

To what degree would you recommend this applicant?

Recommend, Unconditionally

Recommend, with some reservation

Do not recommend

Please explain your choice