Sample Faculty Reference Form
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Faculty Reference Form
Ms/Mr ____________________________ is requesting a reference for the Summer Externship
Program at NYU Langone Medical Center. In order to assist you in making a better evaluation
of the applicant’s qualification and personal attributes, this form is being provided.
Outstanding
Above Average Average Below Average Unable to evaluate
Critical Thinking Skills
Clinical Competence
Professional Attitude
Interpersonal Skills
Organizational Skills
Team Approach
Leadership Potential
Appearance/Grooming
Attendance/ Punctuality
It is my opinion that this student:
Strongly Agree Agree
Disagree
Strongly Disagree
1. Is an independent learner
4
3
2
1
Is trustworthy and assumes
4
3
2
1
2.
responsibility for actions
Is self motivated and reliable
4
3
2
1
3.
Knows when to ask for assistance
4
3
2
1
4.
Has a strong work ethic
4
3
2
1
5.
Utilizes constructive criticism
4
3
2
1
6.
Is in good academic standing
4
3
2
1
7.
Is a good candidate for this
8.
program/position
Comments:
Semester associated with applicant: ______________________
Title: ____________________
Faculty name: ______________________________________
Date: _____/_____/_____
Faculty Signature: ____________________________________
School of Nursing: ___________________________________
NYU Langone Medical Center - Office of Nurse Recruitment
545 First Ave. GBH-C-10, New York, NY 10016
Phone: 212-263-5752
Fax: 212-263-8448
Email:
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Parent category: Letters