SECTION 1: Completed by applicant. Please Print.

APPLICANT NAME: Last:_________________________ First:__________________ Middle:_______________ Maiden:________________

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:__________

After completing Section 1, the applicant should deliver this form to the reference with a stamped envelope addressed to:
University of Southern Indiana
College of Nursing and Health Professions
Attn: Student Advising Center
8600 University Boulevard
Evansville, Indiana 47712

SECTION 2 Completed by reference. Please Print.
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

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

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 on a separate page.

Signature: _____________________________ Date: ________________________

Please print name: _____________________________

Title: _____________________________

Institution: _____________________________

City/State: _____________________________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