Letter of recommendation
Student Name
*
Professional relationship with the applicant?
*
Student
Colleague
Supervisor
How frequently did you observe the applicant?
*
Daily
Weekly
Monthly
How long have you known the applicant?
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Months or Years
Are you related to the applicant in any manner?
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Yes
No
Please provide your rating for the following points:
4=Excellent 3= Above Average 2=Average 1=Below Average U=Unable To Evaluate
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4
3
2
1
U
Punctuality
Basic knowledge
Work Ethics
Academic performance
Ethical Conduct
SAT/ACT scores
Compassion and desire to care for others
Use of computers and technical skills
Volunteer work or medical externships
Ability to understand & speak English
Communication skills
Clinical skills
Cooperativeness
Ability to work with others
To your knowledge, the applicant had a history of intemperate use of alcohol or drugs
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Yes
No
If Yes, please explain
*
To your knowledge, the applicant had a history of disciplinary action
*
Yes
No
If Yes, please explain
*
To your knowledge, the applicant had a history of criminal activity
*
Yes
No
If Yes, please explain
*
Summary
*
I am recommending the applicant without any hesitation
I am recommending the applicant with the limitations specified below
I do not recommend this applicant for the reasons below
Additional Comments
*
Additional Documents
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Reference provided by:
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Date
*
-
Month
-
Day
Year
Date
Email
*
example@example.com
Phone Number
*
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