Postgraduate Physician Assistant Critical Care Residency Program Application Form (Page 3 of 4) in pdf

APPLICANT EVALUATION FORM

Johns Hopkins Hospital

Postgraduate Physician Assistant Surgical Residency

APPLICANT’S WAIVER OF RIGHT

OF ACCESS TO CONFIDENTIAL

STATEMENT: I hereby freely and

Applicant

: Please fill in your name, social security number and mailing

voluntarily waive my right of access

address, and sign waiver. Provide a standard business size envelope to

to any information contained on this

evaluator.

recommendation form and agree

that the statement shall remain

confidential.

Evaluator:

Because of federal legislation giving students access to

educational records, the PA Surgical Residency Program cannot

____________________________

guarantee the confidentiality of your statement unless the applicant

(signature)

has signed the Waiver printed at right.

____________________________

(date)

Applicant’s Name: __________________________________________

__________________________

Last

First

Middle

Social Security Number

Applicant’s Mailing Address:

_________________________________________________________________________

Street

City

State

Zip

_________________________________________________________________________________________

To the person recommending the applicant: The Johns Hopkins Hospital Postgraduate PA Surgical

Residency Program greatly appreciates your completion of this form. Please return this form directly to the

applicant. Seal your evaluation in the envelope provided by the applicant, and write your name across the back

seal.

For how long, and in what relationship, have you known the applicant? ____________________________

_________________________________________________________________________________________

Please comment on the strength and weaknesses of the candidate according to your knowledge of him/her, in

the following areas:

Intellectual Ability: ________________________________________________________________________

_________________________________________________________________________________________

Motivation/Perseverance:___________________________________________________________________

_________________________________________________________________________________________

Ability To Work With Others: ________________________________________________________________

_________________________________________________________________________________________

Postgraduate Physician Assistant Critical Care Residency Program Application Form Page 3

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