UNIVERSITY OF SOUTHERN INDIANA
GRADUATE NURSING PROGRAM
APPLICANT REFERENCE


SECTION 1 (to be completed by applicant.)

After completing Section 1, the applicant should deliver this form to the reference with a stamped envelope addressed to: University of Southern Indiana, ATTN: Graduate Nursing, 8600 University Boulevard, Evansville, Indiana 47712.

APPLICANT NAME
Last_________________________ First__________________ Middle_______________ Other________________________

Last (Maiden)______________________ Social Security #______________________

PRESENT ADDRESS
Street______________________City______________________ State__________ Zip______________________

NAME OF REFERENCE
The Family Education Rights and Privacy Act of 1974 and its amendments guarantee students access to the
educational records. Students may waive their rights of access concerning recommendations. The following signed statement is the applicant's desire regarding this recommendation.

I waive the right to inspect the contents of this recommendation
Signature_______________________________ Date_______________________________
I do not waive the right to inspect the contents of this recommendation.
Signature_______________________________ Date_______________________________
I agree to this reference being contacted orally.
Signature_______________________________Date_______________________________


SECTION 2 (to be completed by reference)
The faculty of the Graduate Nursing Program values your comments on the suitability of this applicant for
graduate work. Your comments will be held in confidence if the applicant has signed the above waiver.

How long, and in what capacities have you known the applicant?_______________________________________________________________________
_______________________________________________________________________________

Please carefully assess the applicant in the following areas. In making your assessment, compare the applicant to other individuals you have known who have similar levels of experience and education.

 
Very Good
Good
Average
Adequate
Poor
Unknown
 
(top 5%)
(top 10%)
(top 20%)
(top 30%)
(top 50%)
(lower 50%)
Intellectual ability
Ability to analyze a problem
and formulate a solution
Competence in applicants general field
Self-reliance
Leadership
Creativity/innovation
Motivation
Self-discipline
Cooperativeness
Oral communication
Written communication skills
Initiative
Reliability

REFERENCE
We are interested in obtaining a profile of the applicant's capability for graduate study. We realize that check-off items sometimes do not provide you the opportunity to characterize the applicant as fully as you would like. Please provide any additional comments in the space below (or on a separate page.)

 

 

Your overall assessment of the applicant as to his or her ability to complete an advanced academic degree:

Highly recommend

Recommend with reservation
Recommend Do not recommend

Signature_____________________________ Date________________________

Please print name_____________________________

Institution_____________________________

Address_____________________________

Your position_____________________________Telephone number (______)___________________

It is the policy of the University of Southern Indiana to be in full compliance with all federal and state non-discrimination and Equal Opportunity laws, orders, and regulations relating to race, sex, religion, disability, age, national origin, sexual orientation, or status as a disabled veteran or veteran of the Vietnam era. Questions or concerns should be directed to the Affirmative Action Officer, USI Human Resources Department, University of Southern Indiana, 8600 University Boulevard, Evansville, IN 47712